RESUMEN
In the context of all of the discussion about "Fletcherian" ethics consultation, we're including this description of ethics consultation for clarity and in deference to the work of John C. Fletcher. It's reprinted from the third edition of Fletcher's Introduction to Clinical Ethics.
Asunto(s)
Consultoría Ética , HumanosRESUMEN
Over the past 25 years fetal reduction has been utilized to reduce the risks of higher-order multiple pregnancies that have resulted from overly successful infertility therapies. The demographics of multiple pregnancy patients have evolved over the past decade, with increasing proportions coming from IVF as opposed to ovulation induction, being older and a higher proportion with donor eggs. Genetic diagnosis prior to reduction is becoming more common and is very safe in experienced hands. For all starting numbers, including twins, reduction to a lower number of fetuses reduces fetal losses, prematurity, and infant mortality and morbidity.
Asunto(s)
Fertilización In Vitro , Reducción de Embarazo Multifetal , Gemelos , Femenino , Humanos , Embarazo , Resultado del Embarazo , Reducción de Embarazo Multifetal/ética , Reducción de Embarazo Multifetal/tendencias , Estados UnidosRESUMEN
OBJECTIVE: In the past, our group took the position that we would not provide multifetal pregnancy reduction to a singleton regardless of starting number except for serious maternal medical indications or as a selective termination for diagnosed fetal anomalies. With evidence of increased safety and more women (many aged 40 years or more) asking for counseling about reduction to a singleton, we reviewed our prior reasoning. METHODS: We compared outcomes of 52 first-trimester twin-to-singleton for multifetal pregnancy reduction cases performed by a single operator to twin and singleton data from recent national register studies. RESULTS: Twin-to-singleton reductions represent less than 3% of all cases. Forty of 52 patients were aged 35 years or more, 19 were aged more than 40 years, and 2 were aged more than 50 years (age range 32-54 years). Since 1999, 23 of 28 had chorionic villus sampling before multifetal pregnancy reduction. Fifty-one of 52 reached viability with mean gestational age at delivery of 37.2 weeks. One of 52 patients miscarried (1.9%). Compared with multiple sources of data for twins, the loss rate is lower in twins reduced to a singleton. CONCLUSION: Until recently, multifetal pregnancy reductions to a singleton were rare. Physicians were concerned about the unknown risks of multifetal pregnancy reduction in this situation. They also had moral doubts about the justification to go "below twins." However, physicians know that spontaneous twin pregnancy losses average 8-10%. Also, with experience, multifetal pregnancy reduction has become very safe in our hands. Our data suggest that the likelihood of taking home a baby is higher after reduction than remaining with twins. We propose that twin-to-singleton reductions might be considered with appropriate constraints and safeguards.
Asunto(s)
Reducción de Embarazo Multifetal , Gemelos , Aborto Espontáneo , Adulto , Muestra de la Vellosidad Coriónica , Femenino , Humanos , Edad Materna , Persona de Mediana Edad , Embarazo , Reducción de Embarazo Multifetal/estadística & datos numéricos , Primer Trimestre del Embarazo , Embarazo de Alto RiesgoAsunto(s)
Experimentación Humana/ética , Enfermedad de Parkinson/cirugía , Placebos , Ensayos Clínicos Controlados Aleatorios como Asunto/ética , Proyectos de Investigación , Procedimientos Quirúrgicos Operativos/ética , Decepción , Trasplante de Tejido Fetal , Humanos , National Institutes of Health (U.S.) , Enfermedad de Parkinson/tratamiento farmacológico , Juicio Moral Retrospectivo , Medición de Riesgo , Procedimientos Quirúrgicos Operativos/efectos adversos , Estados UnidosRESUMEN
We surveyed genetics professionals, patients, and the public about rights to information, to requested services, and to parenthood, posing difficult cases found in practice. In all, 2906 genetics professionals (63%), 499 primary care physicians (59%), 476 North American genetics patients (67%), 394 French patients (51%), 593 German patients (65%), and 988 members of the American public (99%) returned anonymous questionnaires. Results suggest a trend toward increased respect for patient autonomy since an earlier survey in 1985; in most nations more would perform prenatal diagnosis for a couple with 4 daughters who desire a son. A minority (35% in U.S., 14% elsewhere) would perform PND for a deaf couple who want a deaf child, but most (94% in U.S., 62% elsewhere) would do prenatal paternity testing in the absence of rape or incest. About half (51%) would support a woman with fragile X who wants children. The trend to respect patient autonomy was greatest in the U.S. and was least evident in China and India. In general, responses to these cases illustrate a shift away from population or eugenic concerns to a model of genetics focused on the individual.
Asunto(s)
Aborto Eugénico , Actitud del Personal de Salud , Actitud , Asesoramiento Genético , Servicios Genéticos , Internacionalidad , Pacientes/psicología , Autonomía Personal , Diagnóstico Prenatal , Análisis para Determinación del Sexo , Aborto Eugénico/psicología , Acceso a la Información , Asia , Recolección de Datos , Sordera , Personas con Discapacidad , Europa (Continente) , Femenino , Asesoramiento Genético/psicología , Asesoramiento Genético/estadística & datos numéricos , Enfermedades Genéticas Congénitas , Pruebas Genéticas , Humanos , América Latina , Masculino , América del Norte , Paternalismo , Paternidad , Derechos del Paciente , Opinión Pública , Derivación y Consulta , Negativa al Tratamiento , Estrés Psicológico , Encuestas y Cuestionarios , Recursos HumanosAsunto(s)
Enfermedades Fetales/terapia , Investigación Fetal , Terapia Genética , Investigación , Medición de Riesgo , Riesgo , Aborto Eugénico , Comités Consultivos , Investigaciones con Embriones , Padre , Asesoramiento Genético , Enfermedades Genéticas Congénitas , Ingeniería Genética , Mejoramiento Genético , Servicios Genéticos , Pruebas Genéticas , Células Germinativas , Asignación de Recursos para la Atención de Salud , Experimentación Humana , Humanos , Consentimiento Informado , Métodos , Selección de Paciente , Embarazo , Mujeres Embarazadas , Diagnóstico Preimplantación , Diagnóstico Prenatal , Política Pública , Técnicas Reproductivas Asistidas , Sujetos de Investigación , Asignación de RecursosRESUMEN
At this stage, JCAHO [Joint Commission on Accreditation of Healthcare Organizations] site visitors simply want to know how the institution plans to respond to the organization ethics standard. In the near future, however, they will expect data on how ethical issues have been addressed that faced the organization in marketing, billing, managed care contracts, and so on. Pointing to an organizational code of ethics will not be enough. Examples of leadership utilizing the processes of the committee or an appropriate consultant or group, to the ends of education, policy studies, and consultation on specific choices will meet the standard. Organizations that evade or choose not to supply data along these lines will presumably be negatively evaluated. Noncompliance presumably means a risk to accreditation. The message to the clinical ethics committee is a serious one. We must engage in the regional planning and organization needed to provide education and training needed by ethics committees for these two tasks, within the constraints of realism, that is, that these are requirements that are primarily expected of the clinical community and the organizations that provide care to patients.
Asunto(s)
Comités de Ética Clínica , Comités de Ética , Instituciones de Salud , Joint Commission on Accreditation of Healthcare Organizations , Política Organizacional , Defensa del Paciente , Derechos del Paciente , Estándares de Referencia , Responsabilidad Social , Personal Administrativo , Directivas Anticipadas , Ética Institucional , Ética Profesional , Personal de Salud , Humanos , Consentimiento Informado , Estados UnidosAsunto(s)
Eticistas , Ética , Competencia Profesional , Estándares de Referencia , Canadá , Educación , Comités de Ética , Consultoría Ética , Ética Clínica , Ética Médica , Enfermeras y Enfermeros , Médicos , Rol Profesional , Estados UnidosAsunto(s)
Niño , Investigación Genética , Terapia Genética , Genética , Experimentación Humana , Personas con Discapacidades Mentales , Coerción , Revelación , Revisión Ética , Ética , Comités de Ética , Comités de Ética en Investigación , Gobierno Federal , Enfermedades Genéticas Congénitas , Ingeniería Genética , Mejoramiento Genético , Células Germinativas , Gobierno , Regulación Gubernamental , Guías como Asunto , Asignación de Recursos para la Atención de Salud , Historia , Historia del Siglo XX , Humanos , Lactante , Consentimiento Informado , Inteligencia , Competencia Mental , Métodos , Consentimiento Paterno , Selección de Paciente , Sujetos de Investigación , Asignación de Recursos , Riesgo , Medición de Riesgo , Mala Conducta Científica , Control Social Formal , Justicia Social , Consentimiento por Terceros , Estados UnidosAsunto(s)
Humanos , Confidencialidad/ética , Consentimiento Informado/ética , Educación Profesional/ética , Educación Primaria y Secundaria , Genética Médica/ética , Servicios Genéticos/ética , Ética Basada en Principios , Adopción , Bases de Datos de Ácidos Nucleicos/ética , Diagnóstico Preimplantación/ética , Diagnóstico Prenatal/ética , Educación , Estructuras Embrionarias , Eugenesia , Predisposición Genética a la Enfermedad/genética , Suiza , Terapia Genética/éticaAsunto(s)
Toma de Decisiones , Terapia Genética , Células Germinativas , Investigaciones con Embriones , Eugenesia , Libertad , Investigación Genética , Genética , Regulación Gubernamental , Humanos , Cooperación Internacional , Internacionalidad , Principios Morales , Investigación , Control Social FormalAsunto(s)
Comités Consultivos , Discusiones Bioéticas , Bioética , Gobierno Federal , Gobierno , Política Pública , Aborto Inducido , Síndrome de Inmunodeficiencia Adquirida , Investigación Biomédica , Diversidad Cultural , Atención a la Salud , Investigaciones con Embriones , Investigación Fetal , Trasplante de Tejido Fetal , Financiación Gubernamental , Libertad , Objetivos , Regulación Gubernamental , Historia , Experimentación Humana , Humanos , Principios Morales , Política , Investigación , Control Social Formal , Valores Sociales , Estados UnidosRESUMEN
CONCLUSION: I hope that this response to Scofield's paper has accomplished two goals: 1) it helps put to rest unreal discussion of a "profession" of clinical ethics and 2) it helps to focus on the most important issues raised by Scofield upon which action can be taken. It is true that "ethics is everybody's business" and ethicists must restrain their bias when it comes to the decision-making process. But special knowledge and skills are required to nurture the elements of a clinical ethics program, to unite the efforts of its multitalented members, and to relate the literature of a rapidly growing activity in healthcare to practical projects. The issues raised in the constructive parts of Scofield's paper are an excellent point of departure for debate on how best to shape the education, training, and standards of practice for clinical ethics.