Perceptions of COVID-19 patients in the use of bioethical principles and the physician-patient relationship: a qualitative approach.

BACKGROUND: The COVID-19 pandemic has influenced the approach to the health-disease system, raising the question about the principles of bioethics present in physician-patient relations. The principles while widely accepted may not be sufficient for a comprehensive ethical analysis. Therefore, the aim of this study was to explore the perception of these principles and the physician-patient relationship during a hospital stay through a qualitative approach. METHOD: Sixteen semi-structured interviews took place to know the patients' perception during their 2020 hospitalization for COVID-19. The data was analyzed through the constant comparison method, creating categories and comparing them. In the end, seven categories were established and were grouped in three: bioethical principles (dignity, charity, vulnerability, autonomy), doctor-patient relationship (participant commitment, informed consent, health staff-patient relationship) and the experience of the disease (illness, the role of the family). RESULTS: The research found that most patients described a positive experience, with the feeling of having been well cared for with no sense of discrimination or injustice done. The majority also reported that their autonomy was respected in the treatment decisions. The evaluation of these attitudes is an area of opportunity, especially when the patients' vulnerability is at risk. CONCLUSIONS: The ethics of virtue offers a better reflection of how human beings manifest themselves by emphasizing the development of virtuous character and behaviors that allow them to realize their values in life. Authorized by the Research Ethics Committee with registration: DI/18/105-B/3/308.

A.L.L. Y.O.U. N.E.E.D. I.S. L.O.V.E. Manual on health self-management and patient-reported outcomes among low-income young adult Mexicans on chronic dialysis: Feasibility study.

PURPOSE: We evaluated disease knowledge/self-management skills among low-income Mexican young adults maintained on dialysis and to test the effectiveness of the A.L.L. Y.O.U. N.E.E.D. I.S. L.O.V.E (AYNIL) Manual - Spanish Version on patient-reported outcomes. This is a low literacy teaching tool designed with patients and educators' input. DESIGN AND METHODS: A quasi-experimental study was conducted in 17 chronic dialysis patients at Mexico City's Hospital General de México, Dr. Eduardo Liceaga. Ages 18-30-year-old completed disease knowledge/self-management and quality of life measures before the intervention and 6 weeks later. RESULTS: Significant increases were observed on disease knowledge/self-management scores in the STARx questionnaire from 47 (IQ: 40,51) to 50 (IQ: 48,54) p = 0.04. The UNC-TRxANSITION Index increased significantly from 4.8 (IQ: 3.9,5.7) to 7.7 (IQ: 7.5,8.2) p ≤0.001. Significant increases in scores were detected in the "Burden of kidney disease" (p = 0.008), "Effects of kidney disease" " (p = 0.03) and " Dialysis staff encouragement" (p = 0.027) based on the KDQoL survey. CONCLUSIONS: In this vulnerable population, the Spanish version of the A.L.L. Y.O.U. N.E.E.D. I.S. L.O.V.E. - AYNIL Manual improved CKD/ESRD disease knowledge/self-management skills and HRQoL. This study highlighted the need for low-literacy educational tools to improve patient-reported outcomes. PRACTICE IMPLICATIONS: Young adults with CKD/ESRD can benefit from patient-centered educational interventions to enhance their autonomy and the development of self-management behaviors that improve patient-reported outcomes and potential complications of the disease. Special attention is needed in low-income patients with low rates of adherence to treatments and poor self-management skills.

Effect of Oral Nutritional Supplementation With and Without Exercise on Nutritional Status and Physical Function of Adult Hemodialysis Patients: A Parallel Controlled Clinical Trial (AVANTE-HEMO Study).

OBJECTIVE: Protein energy wasting affects the nutritional status (NS) and physical function (PF) of dialysis patients. Among the different anabolic strategies to improve NS and PF, oral nutritional supplementation (ONS) and resistance exercise (RE) or aerobic exercise (AE) have been shown to be effective. Nevertheless, the combination of both anabolic strategies has not been completely evaluated. The aim of this study is to assess the effect of exercise combined with ONS versus ONS without exercise during hemodialysis sessions on PF and NS indicators. METHODS: Young hemodialysis patients (29 ± 9.3 years) with predominantly unknown causes of renal disease (80%) were divided into the following 3 groups during a period of 12 weeks: (1) ONS (n = 15), (2) ONS + RE (n = 15), and (3) ONS + AE (n = 15). Anthropometric, biochemical, PF, and quality of life measurements were recorded at baseline and after 3 months. Repeated measures analysis of variance and effect sizes (Cohen's d) were used to assess the effect of exercise and nutrition (ISRCTN registry 10251828). RESULTS: At the completion of the study, the ONS and ONS + RE groups exhibited statistically significant increases in body weight, body mass index, and in the percentage of fat mass (P < .05); the greatest effect sizes were observed in the ONS + RE group (d = 0.30 for body weight, d = 0.63 for body mass index, and d = 0.90 for the percentage of fat mass). Groups with RE and AE had statistically significant increases and large effect sizes in the six-minute walk test (RE: d = 0.94, P = .02; AE: d = 1.11, P = .03), sit-to-stand test (RE: d = 0.81, P = .041; AE: d = 1.20, P = .002), timed up and go test (RE: d = 1.04, P = .036; AE: d = 1.6, P = .000), and muscle strength (RE: d = 1.01, P = .000; AE: d = 0.60, P = .003). Regarding quality of life, the ONS + RE group had more areas of improvement at the end of the study, followed by the ONS + AE group. No statistically significant differences were found in the repeated measures ANOVA. CONCLUSIONS: The combination of exercise with ONS had larger effects on PF than on ONS alone. Further studies to examine the impact of exercise on the effect of oral nutritional supplementation in dialysis patients are indicated.

The effects of resistance exercise and oral nutritional supplementation during hemodialysis on indicators of nutritional status and quality of life.

BACKGROUND: Protein-energy wasting (PEW) is common in patients undergoing hemodialysis (HD). Studies have assessed the positive effect of oral nutritional supplementation (ONS) or resistance exercise (RE) on nutritional status (NS) markers in patients undergoing HD. METHODS: The aim of this study was to assess the effect of ONS and RE on NS and the quality of life (QOL) of 36 patients undergoing HD. In a randomized clinical trial, patients were divided into the following two groups: a control group (ONS) that received a can of ONS during their HD sessions and an intervention group (ONS + RE) that received a can of ONS and underwent a 40-min session of RE during their HD sessions. Both interventions lasted 12 weeks. The patients' anthropometric, biochemical, dietetic and bioelectrical impedance measurements as well as their QOL, evaluated using the Kidney Disease Quality of Life Short Form, were recorded. RESULTS: At baseline, 55.5% of patients presented with PEW according to International Society of Renal Nutrition and Metabolism criteria (20 patients). We found statistically significant changes from baseline in both groups, such as increases in body weight, body mass index, midarm circumference, midarm muscle circumference, triceps skinfold thickness, fat mass percentage, handgrip strength, phase angle and serum albumin. A decrease in the prevalence of PEW was observed in both groups at the end of the intervention. A delta comparison between groups showed no statistically significant differences in the anthropometric and biochemical parameters. No significant improvement was observed in QOL and body composition measured by bioimpedance vector analysis. Dietary energy and protein intake increased significantly during the study period for all patients. CONCLUSION: Oral nutritional supplementation during HD improves NS. The addition of RE during HD does not seem to augment the acute anabolic effects of intradialytic ONS on NS.

Validation of the UNC TRxANSITION Scale™Version 3 Among Mexican Adolescents With Chronic Kidney Disease.

BACKGROUND: There is a lack of valid health care transition readiness (HCT) scales in Spanish. OBJECTIVE: To provide initial validation of the UNC TRxANSITION Scale™ among Mexican adolescents and young adults (youth) with chronic kidney disease (CKD). METHODS: We used the professionally translated/back translated, provider-administered UNC TRxANSITION Scale™ (Ferris et al., 2012). This 33-question scale measures HCT in ten sub-scales including knowledge about diagnosis or treatment, diet, reproductive health, school/work, insurance, ability to self-manage and looking for new health providers. Its maximum score is 10. We enrolled 163 Mexican adolescents (48.5% females) with CKD stage≥3, mean age of 15.1years (±2.1) and whose primary language is Spanish. There were 15 patients on hemodialysis (9.2%) and 30 transplant recipients (18.4%). Results were compared to those reported in adolescents with chronic conditions from the USA. RESULTS: Our cohort's overall median total score was 5.9. Patients≥16years old had a median total score of 6.4, whereas younger patients had median score of 5.6 (p<0.05). Transplant patients had greater scores in the total and the sub-scales of medication knowledge, issues of reproduction, insurance, trade/work and adherence (p<0.05). When comparing the total score (by age), results from our Mexican youth were similar to those reported in youth from the USA. CONCLUSIONS: In our Mexican cohort of youth with CKD, health care transition readiness is greater in older patients and in transplant recipients. Our cohort's overall score is low, indicating the need for a health care transition preparation program. The UNC TRxANSITION Scale™ results in Mexican youth with CKD are comparable to findings in youth from the USA.

Effect of Intradialytic Oral Nutritional Supplementation with or without Exercise Improves Muscle Mass Quality and Physical Function in Hemodialysis Patients: A Pilot Study.

BACKGROUND: Oral nutritional supplementation (ONS) with or without exercise (EX) could improve muscle mass (MM) in chronic kidney disease. METHODS: Patients were randomized into two groups: (1) ONS and (2) ONS + EX. Thigh muscle area (cm2) and intramuscular lipid content via attenuation were evaluated at baseline and 6 months with computed tomography (CT) to measure MM quantity and quality. Physical function was measured by six-minute walk test (6 MWT), gait speed, handgrip strength (HGS), and Time Up and Go test (TUG) at baseline and 3 and 6 months. RESULTS: The ONS group (n= 14) showed statistically significant improvement in gait speed and HGS; ONS + EX group (n = 10) showed differences in gait speed, in 6 MWT, and HGS. In the ANOVA (3 times × 2 groups), no differences were observed between groups. Greater effect sizes in favor to ONS + EX group were observed in the 6 MWT (d = 1.02) and TUG test (d = 0.63). Muscle quality at six months revealed a significant trend in favor of the EX-group (p = 0.054). CONCLUSIONS: Both groups had improved physical function, and greater effect sizes were seen in the ONS + EX group for the 6 MWT and TUG test. Neither MM quantity or quality was improved in either group.

Validation of the Patient Dignity Inventory in Mexican Cancer Patients.

Introduction: The Patient Dignity Inventory (PDI) is a reliable screening instrument for a variety of problems (physical, existential, and social) that affect the dignity of patients during their end of life. The PDI has been translated into several different languages and has been validated in different settings. As such, it is important to validate the instrument in patients with cancer in Mexico to assess dignity in this population. The aim of this study was to translate and validate the Spanish version of the PDI in Mexican patients with cancer. Methods: This is a cross-sectional study that included patients with cancer, both those enrolled and not enrolled in palliative care, at the Instituto Nacional de Cancerología in Mexico City from September 2018 to August 2019. A translation and back translation were performed to obtain the Mexican version of the PDI (PDI-Mx) instrument. Patients completed the PDI-Mx, the Hospital Anxiety and Depression Scale (HADS), and functional scales (Eastern Cooperative Oncology Group [ECOG] and Karnofsky). Psychometric properties were evaluated by determining internal consistency, exploratory and confirmatory factor analysis (CFA), and concurrent validity with the HADS. Results: We included 290 participants with cancer (145 in palliative care and 145 not enrolled in palliative care). The Cronbach's alpha of the PDI-Mx was 0.95. There was a significant correlation with the HADS (rs = 0.757, p < 0.0001). The factor analysis showed four factors that explain 64.7% of the model. The CFA presented adequate indicators, which show the adjustment of the structure that indicates a balanced and parsimonious model. Conclusions: The Mexican version of the PDI shows adequate psychometric properties in patients with cancer. We suggest the use of PDI-Mx in clinical care and research. The study was approved by the Institutional Review Board and Ethics Committee with numbers (016/063/CPI) and (CEI/1115/16) respectively.

Decreased Autonomy In Community-Dwelling Older Adults.

PURPOSE: The present study aims to explore characteristics associated with low perception of autonomy among community-dwelling older adults. PATIENTS AND METHODS: This original research was derived from a cross-sectional study based on the study COSFOMA with information from 1,252 (60 years and older) community-dwelling older adults whose data was obtained through a questionnaire that included sociodemographic characteristics, as well as different scales of geriatric assessment. The perception of autonomy was evaluated with the autonomy sub-scale of the Quality of Life Scale of Older Adults from the World Health Organization (World Health Organization Quality of Life of Older Adults, WHOQOL-OLD). RESULTS: The mean (SD) age of the 1,252 community-dwelling older adults participating in the study was 68.5 (7.2) years. The average perception of autonomy was 65.3 (18.2) points out of 100. In the final logistic regression model, schooling <6 years (Odds Ratio, OR = 2.1, 95% Confidence Interval, CI = 1.5-2.9), low social support (OR = 1.6, 1.2-2.2), low spirituality (OR = 2.6, 95% CI = 1.9-3.4), presence of cognitive impairment (OR = 1.9, 95% CI = 1.4-2.5), anxiety (OR = 1.7, 95% CI = 1.2-2.5), and limitation in activities of daily living (ADL) (OR = 1.6, 95% CI = 1.1-2.2) were statistically associated with the presence of low autonomy in older adults. CONCLUSION: The perception of autonomy among community-dwelling older adults is moderate. Social support and spirituality, as well as cognitive impairment, anxiety, and limitations in ADL, play a significant role for degree of perceived autonomy in this population. Health professionals can use this information to promote participation in decision-making processes through programs that improve quality of life.

[The horizon of medical attention in pediatrics: what to do in the case of children who are in abandonment, conflict, harm or danger situations in combination with a severe disease?] / El horizonte de la atención médica en pediatría: ¿qué hacer en el caso de niños que se encuentran en situación de abandono, conflicto, daño o peligro, aunado a una enfermedad grave?

Background: Laws refer that minors do not have the capability to give informed consent for their own medical attention. However, there are special conditions in which they are allowed to decide about their health. The greater the judgement and experience limitations in minors, the less weight is given to the values and objectives they express. Also, the more adverse consequences might be, the higher the level of authority that is demanded to decide on behalf of the minor, thus granting the State the capability to guarantee the well-being of the minor. Case report: 12-year-old female patient with a diagnosis of acute lymphoblastic leukemia, with precarious social and family background; evolution of the disease obstructed by the disregard of the treatment due to her unsanitary and extreme poverty conditions. Both of her parents died soon after the start of the treatment and she was kept under the care of her half-sister of legal age. The work and the ethical dilemma of the pediatrician and the staff of Hospital Infantil de México Federico Gómez are exposed within the building of support -networks with the objective of prioritizing the minor's well-being, without allowing family break-up or disintegration, thus succeeding in her recovery. Conclusions: The case was submitted to the Hospital Bioethics Committee. Inter-institutional support networks were built in order to improve dynamics of the family, thus solving the needs of the minor. Despite the misfortune of the situation, the disease was successfully overcome.

Introducción: Las leyes refieren que los menores no tienen la capacidad para dar su consentimiento informado para su propia atención médica; sin embargo, hay condiciones especiales en las que se les permite determinar lo referente a su salud. Cuanto mayores sean las limitaciones de juicio y experiencia en los menores, menos peso se otorga a los valores y objetivos que expresan; cuanto más adversas sean las consecuencias, se deberá exigir un nivel más alto de autoridad para decidir en nombre del menor, dejando al Estado la capacidad de garantizar el bienestar del menor. Caso clínico: Niña de 12 años con diagnóstico de leucemia linfoblástica aguda LI, con antecedentes familiares y sociales precarios; evolución entorpecida por el desapego al tratamiento y sus condiciones insalubres y pobreza extrema. Ambos padres fallecieron al poco tiempo de iniciar su tratamiento, quedando ella al cuidado de su medio hermana mayor de edad. Se exponen la labor y el dilema ético del oncólogo tratante y del personal del Hospital Infantil de México Federico Gómez en la creación de redes de apoyo con el objetivo de priorizar el bienestar de la menor, sin dar lugar al quebrantamiento y la desintegración familiar, consiguiendo exitosamente su recuperación. Conclusiones: El caso fue sometido al Comité de Bioética Hospitalaria. Se formaron redes de apoyo interinstitucionales para intervenir en la dinámica familiar, resolviendo los requerimientos de la menor, y se consiguió con éxito superar la enfermedad.

Mortality in Patients With Chronic Renal Disease Without Health Insurance in Mexico: Opportunities for a National Renal Health Policy.

INTRODUCTION: Despite a systematic increase in the coverage of patients with end-stage renal disease (ESRD) who have received dialytic therapies and transplantation over the past 2 decades, the Mexican health system currently still does not have a program to provide full coverage of ESRD. Our aim was to analyze mortality in patients with ESRD without health insurance. METHODS: This was a prospective cohort study of 850 patients with advanced chronic kidney disease (CKD). Risk factors associated with death were calculated using a Cox's proportional hazards model. We used the statistical package SPSS version 22.0 for data analysis. RESULTS: The mean age of patients was 44.8 ± 17.2 years old. At the time of hospital admission, 87.6% of the population did not have a social security program to cover the cost of renal replacement treatment, and 91.3% of families had an income below US$300 per month. During the 3 years of the study, 28.8% of the cohort patients were enrolled in 1 of Mexico's social security programs. The 3-year mortality rate was of 56.7% among patients without access to health insurance, in contrast to 38.2% of patients who had access to a social security program that provided access to renal replacement therapy (P < 0.001). Risk factor analysis revealed that not having health insurance increased mortality (risk ratio: 2.64, 95% confidence intervals: 1.84-3.79; P = 0.001). CONCLUSION: Mexico needs a coordinated National Kidney Health and Treatment Program. A program of this nature should provide the basis for an appropriate educational and intervention strategy for early detection, prevention, and treatment of patients with advanced chronic kidney disease.

Construction and Validation of a Questionnaire to Assess the Physician-Patient Relationship and its Association with Bioethical Principles / Construcción y validación de un cuestionario para evaluar la relación médico-paciente y su asociación con los principios bioéticos / Construção e validação de um questionário para avaliar a relação médico-paciente e sua associação com os princípios bioéticos

Abstract Physician-patient relationship (PPR) is a professional-interpersonal relationship that serves as the basis for health management. We aimed to develop an instrument for patients to assess the medical attention received in the outpatient clinic. A 21 question instrument was administered to evaluate its reliability and consistency. The intraclass correlation coefficient was 0.81 (p < 0.05); to fulfill the bioethical principles, the intraclass correlation coefficient was 0.740 (p < 0.05), allowing us to get familiar with the perception of patients who attended the Nephrology Service. The survey showed autonomy as the most reported principle (69 %), followed by dignity (67 %) and justice (60 %). Courtesy, punctuality, and respect make the disease and its treatment more bearable, in addition to promoting the ethics of third parties.

Resumen La relación médico-paciente (RMP) es una relación profesional-interpersonal base para la gestión de la salud. Nuestro objetivo fue desarrollar un instrumento que permitiera evaluar la presencia de los principios bioéticos en la atención médica recibida en la consulta externa de una institución hospitalaria. El instrumento quedó constituido por 21 reactivos para evaluar su confiabilidad y consistencia. El coeficiente de correlación intraclase fue de 0,81 (p < 0,05); para el cumplimiento de los principios bioéticos, fue de 0,740 (p < 0,05). El cuestionario mostró que la autonomía fue el principio más reportado (69 %), después la dignidad (67 %) y justicia (60 %). La presencia de los principios de la bioética ampliados hace más llevadera la enfermedad.

Resumo A relação médico-paciente é uma relação profissional interpessoal, base para a gestão da saúde. Nosso objetivo foi desenvolver um instrumento que permitisse avaliar a presença dos princípios bioéticos na atenção médica recebida na consulta de uma instituição hospitalar. O instrumento foi constituído de 21 reativos para avaliar sua confiabilidade e consistência. O coeficiente de correlação intraclasse foi de 0,81 (p < 0,05); para o cumprimento dos princípios bioéticos, foi de 0,740 (p < 0,05). O questionário mostrou que a autonomia foi o princípio mais relatado (69%), depois da dignidade (67%) e da justiça (60%). A presença dos princípios da bioética ampliados torna a doença mais suportável.

Self-Management and Health Care Transition Among Adolescents and Young Adults With Chronic Kidney Disease: Medical and Psychosocial Considerations.

Health care transition (HCT) is a process that requires preparation as a continuum from pediatric- to adult-focused services. For adolescents and young adults with chronic or ESRD, this process can be prolonged due to their physical, psychological, family, or ecological factors. HCT preparation is a matter of patient safety and patient rights as the consequences of poor preparation at the time of transfer to adult-focused services are great, including rejection of organs, disease relapse, or even death. We present a case to illustrate important points of HCT preparation, with suggestions for intervention by the interdisciplinary team members who serve (and will serve) these survivors of pediatric-onset health conditions. To monitor the HCT process, yearly measurements of skill mastery need to take place guide interventions.

Estudio comparativo del conocimiento de las técnicas de reproducción asistida en estudiantes de medicina de universidades con diferentes idearios éticos y humanísticos / Comparative study of the knowledge of IVF in medical students of universities with different ethical and humanistic values / Estudo comparativo do conhecimento das técnicas de reprodução assistida em estudantes de Medicina de universidades com diferentes ideários éticos e humanísticos

Resumen La fertilización in vitro (FIV) se sigue presentando como una solución relativamente sencilla para producir un embarazo sin dar a conocer la problemática médica y ética que esta representa. Este proyecto consistió en realizar una encuesta a los estudiantes de tres facultades de Medicina de la Ciudad de México, con diferentes idearios éticos y humanísticos, con el objetivo de evaluar el conocimiento sobre las técnicas de fecundación in vitro y sus implicaciones éticas. Se aplicó una encuesta a 404 alumnos de medicina. Los alumnos de escuelas con ética personalista tuvieron un mayor reconocimiento de los principios bioéticos implicados en el uso de estas técnicas. El conocimiento de la técnica y de las cuestiones éticas implicadas en la reproducción asistida podría mejorar la sensibilidad de los alumnos de medicina ante dilemas éticos que se presenten en su ejercicio profesional.

Abstract In vitro fertilization (IVF) continues to be presented as a relatively simple solution to produce a pregnancy without exposing the medical and ethical problems that this represents. This project consisted of conducting a survey to medical students from three medical schools in Mexico City with different ethical and humanistic ideas with the aim of evaluating knowledge about IVF techniques and their ethical implications. The survey was applied to 404 medical students. Students in schools with personalistic ethics had a greater recognition of the bioethical principles involved in the use of these techniques. Knowledge of the technique and ethical issues involved in assisted reproduction could improve the sensitivity of medical students to ethical dilemmas that arise in their professional practice.

Resumo A fertilização in vitro (FIV) continua sendo apresentada como uma solução relativamente simples para produzir uma gestação sem dar a conhecer a problemática médica e ética que ela representa. Esse projeto consistiu em realizar uma pesquisa com estudantes de três faculdades de Medicina da Cidade do México, com diferentes ideários éticos e humanísticos, com o objetivo de avaliar o conhecimento sobre as técnicas de fecundação in vitro e suas repercussões éticas. Foi aplicada uma pesquisa a 404 alunos de Medicina. Os alunos de escolas com ética personalista tiveram um maior reconhecimento dos princípios bioéticos implicados no uso dessas técnicas. O conhecimento da técnica e das questões éticas implicadas na reprodução assistida poderia melhorar a sensibilidade dos alunos de Medicina ante dilemas éticos que são apresentados em seu exercício profissional.

[Review of models for the analysis of ethical dilemmas]. / Revisión de modelos para el análisis de dilemas éticos.

In pediatric medical practice it is common to encounter situations that represent a dilemma for health professionals. A dilemma occurs when ethical problems found in professional practice cause serious internal conflicts because they imply actions that contradict their colleagues, employees, or their own personal values and are classified as personal value conflicts, conflicts with other professionals, conflicts with clients and with organizations. A literature review allowed identifying different models to debate these types of dilemmas. The present work is a review of the search of scientific articles using databases such as Ebsco Host, ProQuest, Ovid, and InMex as well as metasearch tools such as metacrawler. The models found are as follows: Model of Anne Davis, Nijmegen method, Method of Diego Gracia, Integral method, Bochum Center Ethics model, Model of Brody and Payton, Model of Curtin and Flaherty, Model of Thompson and Thompson, SAD method, Model of Javier Morata, Model of Elaine Congress, IFSW model, Model of Loewenberg and Dolgoff, Ley Social Model, DOER method, Model of Brommer, Model of Corey and Callanan, Model of Pope and Vasquez, Model of Bush, Connell and Denney, Model of Ferrell, Gresham and Fraedrich, and Model of Hunt and Vitell. The key criteria shared in the different models are a) specifying the ethical dilemma, b) description of the facts, c) value definition, moral code and facts, decision making and d) identifying alternative solutions. In order to review the literature, some models are explained with the purpose of identifying and representing critical elements that clinical ethics committees could use in a practical manner in pediatric health institutions in Mexico.

Calidad de la atención médica desde un punto de vista bioético en un hospital oftalmológico de Ciudad de México / Qualidade da atenção médica do ponto de vista bioético em um hospital oftalmológico da Cidade do México / Quality of medical care from an bioethical point of view in an ophthalmological hospital in Mexico City

Resumen: Objetivo: Analizar la percepción de la calidad de la atención médica desde un punto de vista bioético. Material y métodos: Estudio trasversal, analítico, descriptivo y cuantitativo. Utilizamos dos cuestionarios para evaluar la percepción la atención médica en cuanto a los principios bioéticos. Hicimos un análisis descriptivo y bivariado con cada una de las variables, y sacamos un puntaje de las preguntas que se relacionaban con los principios bioéticos. Resultados: Incluimos 252 participantes y encontramos que, durante la atención médica, se cumplieron los siguientes principios: 14% autonomía, 72% beneficencia, 51% dignidad, 30% integridad, 42% justicia, 52% no maleficencia y 27% vulnerabilidad. 3% obtuvo todos los principios bioéticos. Conclusiones: Uno de los grandes retos de la medicina es la implementación de modelos de calidad de la atención médica, que garanticen que los pacientes reciban una atención médica que tome en cuenta los principios bioéticos.

Resumo: Objetivo: Analisar a percepção da qualidade da atenção médica do ponto de vista bioético. Material e métodos: Estudo transversal, analítico, descritivo e quantitativo. Utilizamos dois questionários para avaliar a percepção da atenção médica quanto aos princípios éticos. Realizamos uma análise descritiva e bivariada com cada uma das variáveis e extraímos uma pontuação das perguntas que se relacionavam com os princípios bioéticos. Resultados: Incluímos 252 participantes e encontramos que, durante a atenção médica, cumpriram-se os seguintes princípios: 14% autonomia, 72% beneficência, 51% dignidade, 30% integridade, 42% justiça, 52% não maleficência e 27% vulnerabilidade. 3% obteve todos os princípios bioéticos. Conclusões: Um dos grandes desafios da medicina é a implementação de modelos de qualidade da atenção médica, que garantam que os pacientes recebam uma atenção médica que leve em conta os princípios bioéticos.

Abstract: Objective: To analyze the perception of the quality of medical care from a bioethical point of view. Methods: Cross-sectional, analytical, descriptive and quantitative study. We used two questionnaires to assess the perception of medical care regarding bioethical principles. We did a descriptive and bivariate analysis with each one of the variables, and we obtained a score of the questions related to the bioethical principles. Results: We included 252 participants and found that during medical care, the following principles were met: 14% Autonomy, 72% Beneficence, 51% Dignity, 30% Integrity, 42% Justice, 52% No Maleficence and 27% Vulnerability. 3% obtained all the bioethical principles. Conclusions: One of the significant challenges of medicine is the implementation of quality models of medical care, which guarantee that patients receive medical care that takes into account bioethical principles.

El horizonte de la atención médica en pediatría: ¿qué hacer en el caso de niños que se encuentran en situación de abandono, conflicto, daño o peligro, aunado a una enfermedad grave? / The horizon of medical attention in pediatrics: what to do in the case of children who are in abandonment, conflict, harm or danger situations in combination with a severe disease?

Resumen: Introducción: Las leyes refieren que los menores no tienen la capacidad para dar su consentimiento informado para su propia atención médica; sin embargo, hay condiciones especiales en las que se les permite determinar lo referente a su salud. Cuanto mayores sean las limitaciones de juicio y experiencia en los menores, menos peso se otorga a los valores y objetivos que expresan; cuanto más adversas sean las consecuencias, se deberá exigir un nivel más alto de autoridad para decidir en nombre del menor, dejando al Estado la capacidad de garantizar el bienestar del menor. Caso clínico: Niña de 12 años con diagnóstico de leucemia linfoblástica aguda LI, con antecedentes familiares y sociales precarios; evolución entorpecida por el desapego al tratamiento y sus condiciones insalubres y pobreza extrema. Ambos padres fallecieron al poco tiempo de iniciar su tratamiento, quedando ella al cuidado de su medio hermana mayor de edad. Se exponen la labor y el dilema ético del oncólogo tratante y del personal del Hospital Infantil de México Federico Gómez en la creación de redes de apoyo con el objetivo de priorizar el bienestar de la menor, sin dar lugar al quebrantamiento y la desintegración familiar, consiguiendo exitosamente su recuperación. Conclusiones: El caso fue sometido al Comité de Bioética Hospitalaria. Se formaron redes de apoyo interinstitucionales para intervenir en la dinámica familiar, resolviendo los requerimientos de la menor, y se consiguió con éxito superar la enfermedad.

Abstract: Background: Laws refer that minors do not have the capability to give informed consent for their own medical attention. However, there are special conditions in which they are allowed to decide about their health. The greater the judgement and experience limitations in minors, the less weight is given to the values and objectives they express. Also, the more adverse consequences might be, the higher the level of authority that is demanded to decide on behalf of the minor, thus granting the State the capability to guarantee the well-being of the minor. Case report: 12-year-old female patient with a diagnosis of acute lymphoblastic leukemia, with precarious social and family background; evolution of the disease obstructed by the disregard of the treatment due to her unsanitary and extreme poverty conditions. Both of her parents died soon after the start of the treatment and she was kept under the care of her half-sister of legal age. The work and the ethical dilemma of the pediatrician and the staff of Hospital Infantil de México Federico Gómez are exposed within the building of support networks with the objective of prioritizing the minor's well-being, without allowing family break-up or disintegration, thus succeeding in her recovery. Conclusions: The case was submitted to the Hospital Bioethics Committee. Inter-institutional support networks were built in order to improve dynamics of the family, thus solving the needs of the minor. Despite the misfortune of the situation, the disease was successfully overcome.

Propuesta para un juramento del bioeticista / A Proposal for an Bioethicist's Oath / Proposta para um juramento do bioeticista

Resumen La influencia de Hipócrates como padre de la medicina es patente, sobre todo a través del "Juramento hipocrático" que ha iluminado el ejercicio de la profesión desde hace 25 siglos. Las versiones modernas de estos postulados constituyen el marco ético y deontológico de esta ciencia, que también es arte. La bioética surge para enriquecer esa práctica, también cuando la investigación científica utiliza seres humanos, y propone la dignificación de la persona y el respeto a los derechos humanos universales. Ante la aceleración del desarrollo técnico y científico, es imprescindible reforzar la reflexión ética con el fin de que la ciencia permanezca al servicio del hombre y no en detrimento suyo. De ahí la necesidad de un "Juramento del bioeticista".

Abstract The influence of Hippocrates as father of Medicine is clear, particularly through the "Hippocratic Oath" that has characterized the profession for the past twenty-five centuries. Modern versions of these postulates constitute the ethical and deontological framework of this science, which is also art. Bioethics arises to enrich this practice, also when scientific research uses human beings, and proposes the dignification of the person and the respect for universal human rights. Faced with the acceleration of technical and scientific development, it is essential to reinforce ethical reflection so that science remains at the service of man and not to his detriment. Hence the need for an "Oath of the bioethicist".

Resumo A influência de Hipócrates como pai da Medicina é evidente, sobretudo através do "Juramento de Hipócrates", que ilumina o exercício da profissão há 25 séculos. As versões modernas desses postulados constituem o referencial ético e deontológico dessa ciência, que também é arte. A bioética surge para enriquecer essa prática, quando a investigação científica também utilizar seres humanos, e propõe a dignificação da pessoa e o respeito aos direitos humanos universais. Diante da aceleração do desenvolvimento técnico e científico, é imprescindível reforçar a reflexão ética com o objetivo de que a ciência permaneça a serviço do homem, e não em seu detrimento. A partir daí, vem a necessidade de um "juramento do bioeticista".

Fundamentación de los derechos humanos del embrión / The Underpinnings of the human rights of the embryo

Objetivo: fundamentar, con base en la demostración de que el embrión es sujeto de derechos humanos, las obligaciones hacia este que se pueden establecer desde el punto de vista de la autonomía. Materiales y métodos: se efectuó una investigación documental, que se complementó con el contenido de las entrevistas a profundidad que se realizaron a un equipo de expertos des- tacados en la medicina, el derecho y la filosofía, utilizando un guión como instrumento de investigación y conservando la libertad de ampliar algunos de los temas con nuevas preguntas sugeridas por el entrevistado o por el equipo de investigadores, de acuerdo con su pertinencia en el curso de cada entrevista. Resultados: se entrevistaron ocho expertos, dos en medicina, tres en derecho y tres en filosofía. Las entrevistas realizadas ponen en evidencia que existe una fundamentación objetiva de los derechos humanos del embrión, que hoy son conculcados por la supuesta interrupción legal del embarazo, tanto en el modelo de despenalización por excepciones, como en el de la despenalización a plazos. Conclusión: vivimos en una sociedad donde se ha perdido de vista la fundamentación misma del sentido común para proteger al no nacido, especialmente en su etapa embrionaria, apelando a los principios bioéticos de la dignidad, la integridad y la vulnerabilidad.(AU)

Objective: The study was designed to substantiate the obligations to the human embryo that can be established from the stand- point of autonomy, by showing the human embryo to be a subject of rights. Materials and Methods: Documentary research was done, supplemented with content from in-depth interviews conducted with a team of leading experts in medicine, law and philoso- phy. A script was used as a research tool, but with the freedom to expand on some of the issues with new questions suggested by the person being interviewed or by the research team, as relevant to each interview. Results: Eight experts were interviewed: two in medicine, three in rights and three in philosophy. The interviews clearly showed there is an objective basis for the human rights of the embryo, which now are being violated by so-called legal abortion, through decriminalization via exceptions and decriminaliza- tion based on terms. Conclusion: We live in a society that has lost sight of the very foundation of common sense when it comes to protecting the unborn, especially in its embryonic stage, appealing to the bioethical principles of dignity, integrity and vulnerability.(AU)

Objetivo: fundamentar, com base na demonstração de que o embrião é sujeito de direitos humanos, as obrigações que podem ser estabelecidas a ele do ponto de vista da autonomia. Materiais e métodos: efetuou-se uma pesquisa documental que foi comple- mentada com o conteúdo das entrevistas a profundidade realizadas a uma equipe de especialistas destacados em medicina, direito e filosofia; utilizou-se um roteiro como instrumento de pesquisa e conservou-se a liberdade de ampliar alguns temas com novas per- guntas sugeridas pelo entrevistado ou pela equipe de pesquisadores, de acordo com sua pertinência no decorrer de cada entrevista. Resultados: entrevistaram-se oito especialistas (dois em medicina, três em direito e três em filosofia). As entrevistas realizadas de- monstram que existe uma fundamentação objetiva dos direitos humanos do embrião, que hoje são violados pela suposta interrupção legal da gravidez, tanto no modelo de descriminalização por exceções quanto no da descriminalização a prazo. Conclusão: vivemos numa sociedade em que se perdeu de vista a fundamentação em si do sentido comum para proteger o não nascido, especialmente em sua etapa embrionária, apelando aos princípios bioéticos da dignidade, da integridade e da vulnerabilidade.(AU)