A balanced discussion on the ethics of randomized clinical trials should not be based on a single ethical aspect such as respect for the patient's autonomy. Rather, the analysis should consider the ...four ethical principles-respect for autonomy, non-maleficence, beneficence, and justice-as applicable to all groups of persons concerned. We present the ethical benefits and costs of the present practice of randomized clinical trials for four groups: patients involved in clinical trials, patients not involved in trials, participating physicians and society. The ALARA (As Low As Reasonably Achievable) approach is then introduced and practical measures to achieve a positive balance between ethical benefits and costs of randomized trials are proposed.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Several studies have explored the physicians' preferred actions when facing a reluctant or a demanding patient, but only a few studies have explored the physicians' justifying reasons.
The aim of ...this study was to assess how GPs would act and how they would justify their choice.
A postal questionnaire with questions about preferred actions and justifying reasons was sent to a random sample of GPs in Slovenia (n = 160) and Sweden (n = 200) using four vignettes: (i). a healthy patient reluctant to quit smoking; (ii). a healthy patient demanding an X-ray; (iii). a pulmonary cancer patient reluctant to quit smoking; and (iv). a pulmonary cancer patient demanding immunotherapy.
The majority of GPs would bring up the question about smoking with the patients reluctant to quit. They justified their choice by referring to promotion of medical benefit and to protection from harm. Swedish GPs were less inclined to bring up smoking than were their Slovenian colleagues. Those who would not bring up the question referred to respect for self-determination and an enhanced relationship as their justifying reasons. With reference to the demanding patients, a minority of GPs would grant the healthy patient's request for an X-ray that was not medically motivated. The answers were similar with respect to the seriously ill patient requesting non-medically motivated immunotherapy. Slovenian GPs were much more inclined to grant the request than were their Swedish colleagues. Enhancing the relationship and respect for self-determination were the most important reasons for granting the demands. When the demands were denied, the GPs mostly referred to promotion of fair distribution of resources.
Many of the GPs considered their patients' right to self-determination less important than other values, e.g. the obligation to promote medical benefit, to protect from harm, to distribute public resources fairly and to enhance the patient-physician relationship.
It has now been 100 years since Dorothy Reed, at the age of 28, wrote her paper on Hodgkin's disease. Her biography reveals the difficult lives of women entering the hitherto male-dominated field of ...medicine, let alone medical research. Her historic paper on Hodgkin's disease is remarkable for its brilliant observations and concise scientific reasoning. Nevertheless, she was told that as a woman she could not hope for a career as an academic pathologist. After marriage to Charles Elwood Mendenhall, Professor of Physics at the University of Wisconsin and after giving birth to four children, the second part of her career began. Motivated by the loss of her firstborn, she began a study of infant mortality, an interest that lasted throughout her career. In 1926, Mendenhall undertook a survey comparing infant and maternal mortality rates in Denmark and the United States. This influential study concluded that American mortality rates were higher because of unnecessary interference in the natural process of childbirth and recommended the education of midwives follow the Danish model. In 1937, her efforts were rewarded when Madison, WI received recognition for having the lowest infant mortality of any city in the United States. Reading Reed's paper on Hodgkin's disease, we see that her observations go far beyond a description of a specific cell. Her presentation of macroscopic and microscopic features is remarkable for the distinction between "young" and "old" growths: Reed saw Hodgkin's disease as a process, rather than the spreading of a cancer. She was the first to note that those most commonly affected are boys or young adults, especially those whose general health before the disease had been excellent. She was also the first to note anergy to tuberculin. Dorothy Reed defined Hodgkin's disease in relation to tuberculosis, described its pathologic features, and offered comments on its pathogenesis, epidemiology, and immunology that still deserve to be discussed.
Lymphomas and leukemias, as cancers of the immune system, may still retain some susceptibility to regulatory mechanisms which govern the proliferation of their cells of origin. According to this ...concept, an enhanced immune suppression as induced by irradiation and chemotherapy may contribute to their cytotoxic effect in inducing and maintaining a remission of the disease. Cyclosporin selectively and reversibly inhibits activation and proliferation of both normal and neoplastic T lymphocytes. In-vitro experiments and preliminary clinical data from small uncontrolled studies indicate that cyclosporin might be a promising agent in the treatment of mycosis fungoides, Hodgkin's disease, acute leukemia, and possibly other lymphoproliferative disorders, but the experience is still limited and no definitive conclusions may be made. In addition to its direct effect on lymphocytes, cyclosporin reverses the resistance of cancer cells to several antineoplastic agents and may thus find its place in combination with chemotherapy. It is hoped that a more systematic basic and clinical research will help define the role of this new therapeutic approach.
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