Eutanasia: aclarando conceptos

Euthanasia is a subject of permanent discussion everywhere, mainly about its ethical appropriateness and about its legalization in different countries. This debate includes many ethical, legal, social, political, spiritual, religious, and public health issues. A relevant problem is the frequent misunderstanding that many have about the meaning of the terms and concepts used in different ethical and clinical end of life settings. Many views and even texts are affected by such mistakes, rendering a constructive discussion almost impossible. The goal of this article is to contribute to an improvement of the social and legislative discussion about euthanasia through an elucidation of the main terms and notions linked to this topic. We present definitions and explanations for euthanasia, assisted suicide, withdrawal or foregoing of therapy, treatment rejection, palliative sedation, dignified death and others.

Percepción de médicos intensivistas de adultos sobre el aporte de la consultoría ético-clínica / Opinion about clinical ethics consultation among intensivist physicians

Background: Clinical ethics consultation services and their methods vary and they are seldom evaluated. Only one formal system of individual clinical ethics consultation has been reported in Chile, with a ten-year registry. Aim: To evaluate the opinion of intensivist physicians about the contribution of clinical ethics consultation. Material and Methods: An anonymous and voluntary questionnaire consulting their opinion about clinical ethics consultations was sent to 38 intensivist physicians. Results: The questionnaire was answered by 28 professionals. Eighty four percent of respondents considered that ethics consultation contributed to improve patients' quality of care, 92% responded that this practice helps in decisions about limitation of treatments or life support, and 96% expressed that it also was a positive support for patients and their relatives. Seventy two percent of respondents considered that ethics consultations enhanced their ethical sensibility, 76% that they improved their understanding of clinical ethics topics, and 72% declared that it decreased their stress in complex decision-making. Conclusions: Clinical ethics consultation provides a positive support for improvements in clinical decision-making and in the quality of patients' care.

Virus Zika y aborto por correspondencia, una realidad cercana a Chile / Zika virus and correspondence abortion, a reality close to Chile

Ante las evidencias de causalidad entre la infección prenatal de virus ZIKA y el desarrollo de microcefalia y otras anomalías cerebrales fetales, publicadas en el año 2016, en Latinoamérica ha surgido mucha incertidumbre sobre el acceso al aborto en mujeres embarazadas infectadas por el virus. Pese a que existe diversidad regulatoria en la región, hoy existen diferentes instancias que facilitan el aborto farmacológico a las mujeres, incluso en países donde está prohibido. Sin embargo esta realidad no se centra exclusivamente en el brote de virus ZIKA, sino que este hecho ha dejado en evidencia la forma como ONG's internacionales ingresan y facilitan el acceso del aborto farmacológico en diferentes países. Este escenario surgiere la interrogante de cómo enfrenta Chile el desarrollo de esta realidad, ante lo cual se muestra la incidencia de la ONG Women on Web en Chile luego de la alerta epidemiológica emitida por la OPS en noviembre de 2015 por virus ZIKA. Desde Chile se presentaron 442 peticiones de aborto farmacológico en 107 días después de emitida la alerta. Estos datos revelan que en Chile, pese a no estar afectado por virus ZIKA, de hecho se usan las plataformas web que proveen de un "aborto farmacológico por correspondencia". Esta evidencia muestra como hoy en Chile existe acceso al aborto farmacológico, tanto desde ONG's internacionales como la presentada, pero también en el comercio informal, todo promovido desde los alcances de las tecnologías de comunicación.

In lieu of the evidence of causality between prenatal ZIKA virus infection and the development of microcephaly and other fetal cerebral anomalies, published in 2016, there has been a surge of uncertainty in Latin America over the access to abortion in pregnant women infected by the virus. Even though diverse regulation exists in the region, today there are many different instances that facilitate women's to pharmacological abortion, even in countries where it is prohibited. However, this reality doesn't center exclusively in the ZIKA virus outbreak, rather this event has emphasized how international NGOs enter and facilitate access to pharmacological abortion in different countries. This scenario suggests the question of how Chile confronts the development of this reality, in which the marked incidence of the NGO Women on Web is shown in Chile after de epidemiology alert emitted by the PAHO in November of 2015 because of the ZIKA virus. Chile presented 442 petitions for pharmacological abortion in the 107 days following the alert notification. This data reveals that Chile, although unaffected by the ZIKA virus, has use of web platforms that provide a "pharmacological abortion by correspondence". This evidence demonstrates how access to pharmacological abortion exists today in Chile, not only from international NGO like the one mentioned, but even through informal commerce, promoted by the reach of communication technology.

¿Podría ser aceptable la eutanasia infantil? / Could infant euthanasia be ever acceptable?

The recent enactment of a law that allows infant euthanasia in Belgium raises questions with varied answers. To contribute to a better understanding of the topic, euthanasia and legislation concepts are described. After a bioethical analysis, we propose as conclusion that children euthanasia could only be acceptable in very exceptional situations in which palliative measures have failed. The answer should be that it is not acceptable in our setting, not until we have public policies, protocols and palliative care services for terminally ill children.

La reciente promulgación de una ley que permite la eutanasia infantil en Bélgica plantea interrogantes que admiten respuestas diversas. Para contribuir a una mejor comprensión del tema se describen los conceptos de eutanasia y la legislación pertinente. Después de hacer un análisis bioético, se plantea como conclusión que la eutanasia de niños podría ser aceptable sólo de manera muy excepcional ante situaciones en las cuales hubiesen fracasado las medidas de cuidado paliativo. Para nuestro medio la respuesta debería ser que no es aceptable, al menos mientras no existan políticas públicas, protocolos y servicios de cuidados paliativos para niños con enfermedades terminales.

Bárbara, una posible donante de órganos / Barbara, a potential organ donnor

This article presents the case of a 47 year old woman, on encephalic death state, who had not expressed her willing or acceptance for organ donation. The case is described as a narrative, contextualized, and in an anonymous way. A bioethical analysis of the family decision making and of the role of transplant coordinator is proposed. This presentation, with the description of its whole context and of the factors that influenced decisions, has the purpose to contribute to the development of deliberation competencies and to increase the awareness of the ethics problems of family decisions, of the conditions of anonymous organ assignation and of the of the end of life's meanings.

Se presenta el caso de una mujer de 47 años, en muerte encefálica y sin expresiones previas sobre su voluntad de ser donante de órganos. El caso se expone como una narración contextualizada, anonimizada y seguida de un análisis bioético de las decisiones familiares y del rol del coordinador de trasplantes. La presentación, con una descripción del contexto y de los factores que condicionan las decisiones, tiene el propósito de contribuir al desarrollo de la capacidad deliberativa y a tomar mayor conciencia del problema ético de las decisiones familiares, del anonimato de la asignación de órganos y del sentido del final de la vida.

Los estudiantes de medicina como parte del equipo de salud / Medical students as members of the health care team

Background: Teaching hospitals include both undergraduate and postgraduate students, but the role of medical students in the health care team has not been clearly established. Aim: To know the opinion of different professionals about the role of medical students and how this opinion may have an influence in medical education. Material and Methods: A qualitative method was used, asking open questions to focus groups of physicians, nurses and midwives, technicians and undergraduate medical students of 4th and 5th grade. Results: Physicians believe that medical students have no special role in the health care team, nurses think that they may help in commu-nication with patients, and technicians (nurses’s aids) value their companionship and closeness with patients. Medical students recognize that their main function is to learn but they are aware that they do help patients. They suggest increasing their integration with other students of other health related careers. Conclusions: Although medical students are usually not seen as part of the health care team, they may fulfll a role with patients during their clinical learning practice. This would improve the quality of their training and the multidisciplinary work of the health care team.

Análisis de una experiencia de consultoría ético clínica en cuidado intensivo / Analysis of a clinical ethics consultation experience in intensive care

Background: Very few patients are presented to ethics committees, and individual ethics consultations are a response to this situation. At the intensive care unit (ICU) in Clínica Alemana, Santiago Chile, an ethics consultation system was organized coordinated with the ethics committee. Aim: To report an evaluation of this ethics consultation system. Material and Methods: Analysis of the frst 50 cases analyzed in the consultation system. Analysis of the responses of intensive care physicians to a questionnaire about the main ethical problems that they face in their work. Results: The consultation system is mainly required by the ICU staff, and reports to the ethics committee. Fifty four percent of patients subjected to consultation were aged over 80 years. The main diagnoses were neurological, oncological or cardiopulmonary problems. The ethical problems identifed were treatment limitation (62 percent), proportionality or futility (42 percent), need of a peaceful death (36 percent), lack of anticipated decisions (28 percent), disagreement between physicians and patient’s family (24 percent), undefined subrogation (14 percent), and abuse of public resources (14 percent). Twenty six of 31 ICU physicians answered the questionnaire, using a 1 (min) to 7 (max.) scale. They found that consultation is helpful for decision making (6.3), useful for improving ethical perception (6.0), supportive for staff (6.5), good for patients (6.3), supportive for families (6.7), and timely performed (5.2). Conclusions: As a complement for the ethics committee’s work, consultation is a valid alternative for ethics counselling and a support for physicians and patient’s families. Its implementation depends on the particularities of each health institution.

Diez mitos sobre el retiro de la ventilación mecánica en enfermos terminales / Ten myths about withdrawal of mechanical ventilation in terminal patients

The most difficult of treatment limitation decisions, both for physicians and families, is the withdrawal of mechanical ventilation (MV). Many fears and uncer-tainties appear in this decision. They are described as “ten myths” whose falseness is argued in this article. The myths are: 1) Withdrawing MV causes the patient’s death; 2) Withdrawing MV is euthanasia; 3) Withholding and withdrawing MV are morally different; 4) MV can be withdrawn only when the patient has asked for it; 5) Chilean law only authorizes to withdraw VM when brain death has occurred; 6) Withdrawing MV cannot be done if the patient is not an organ donor; 7) Physicians who withdraw MV are in high risk of legal claims; 8) To withdraw MV the physician needs an authorization from the hospital ethics committee, lawyer or institutional authority; 9) There is only one way to withdraw MV; 10) Withdrawing MV produces great suffering to the patient’s family. Making clear that these myths are false facilitates appropriate decisions, therefore preventing “therapeutic obstinacy” and more suffering of terminally ill patients, which favors their peaceful death. For the physician this goal should be as rewarding as preventing the death of a curable patient.

Un análisis del problema ético y legal del tratamiento del cáncer cervicouterino en mujeres embarazadas: [revisión] / Ethical and legal problem in the treatment of cervical cancer in pregnant women: [review]

Se analiza el problema ético y jurídico del tratamiento del cáncer cervicouterino en mujeres embarazadas. Se realizó una revisión del tema, de las leyes chilenas y de algunas normativas europeas para después analizar la aplicación de los principios de No Maleficencia, Beneficencia, Autonomía y del Doble Efecto. El tema genera una difícil discusión e interpretación, pues tanto las leyes como los principios son orientadores, pero no explícitos para decidir la conducta más adecuada en cada caso. Lo ideal es preservar la vida materna y fetal, pero hay casos en los que, finalmente, es necesario priorizar una sobre la otra. Corresponde al equipo tratante, la madre, el padre, la familia y la sociedad concordar las conductas más responsables y justas posibles.

Authors analyze the ethical and legal problem about the treatment of cervical cáncer in pregnant women. A review of the Chilean laws and European regulations was made in order to analyze the application of the principies of Non maleficence, Beneficence, Autonomy and the Double Effect. The subject generates a difficult discussion and interpretation since both, law and principies, are guiding but do not give an explicit answer to choose the more appropriate behavior in each case. The goal is to preserve maternal and fetal life, but there are cases in which it is necessary to prioritize one over the other. A consensus between medical staff, the mother, the father, the family and society is necessary for a more responsible and fair decision.

Cómo enfrenta el hinduismo un dilema ético-clínico / How does Hinduism analyze an ethical clinical dilemma

It is indispensable for physicians to understand and recognize the fusion of different cultures, to deliver the best possible service to patients with different cultural backgrounds, especially when ethical-medical problems are involved. The Hindu community in Chile differs in significant ways with the western culture. This is especially true for some issues such as the belief in reincarnation or gender inequality, among others. These discrepancies can be relevant for the analysis of several bioethical problems. Therefore, it is necessary to understand the different beliefs, traditions and Hindu visions. We hereby present a review of Hinduism, its relation with medical practice and, as an example, a case of abortion in a Hindu family. Reviewing the traditions, beliefs and methods will help to understand and respect the beliefs of different cultures in contemporary and globalized bioethics.

Los medios de comunicación y los avances biomédicos / Mass media communication of biomedical advances

The public dissemination of advances in biomedical research and clinical medicine generates several difficulties and problems. Mass media have the responsibility to report accurately and in a comprehensive way, and physicians and researchers mustprovide this information in a timely manner and without bias. Afíer reviewing the ¡iterature related to this subject and discussing some examples of inadequate information in the Chilean context, the authors suggest the foüowing recommendations: journalists should compare and evalúate the information appropñately before its publication, researchers and journalists should work together, reports should inform clearly about the state of the research and every academic institution should avoid reporting publicly preliminary experiences. If these recommendations are foüowed, the general public, physicians, researchers and health care institutions will be benefited.

Tres factores que influyen en la actitud de las personas ante la donación de órganos: [revisión] / Three influencing factors in people's attitude towards organ donation: [revision]

Se analiza la donación de órganos de cadáver para trasplantes a partir de tres postulados: 1) la influencia de la religión en la donación, particularmente del catolicismo; 2) la organización del sistema de información y acercamiento al donante y su familia, y 3) la formación personal de los miembros del equipo de salud. En la religión se encuentra una disociación entre la norma moral propuesta y la visión de los fieles. España, con su modelo de la Organización Nacional de Trasplantes, es el referente con una alta tasa de donación de órganos y gran credibilidad social en el sistema. El último postulado hace referencia a la importancia de contar con profesionales especialmente capacitados en la materia y en habilidades de comunicación. Se plantea la necesidad de tomar medidas administrativas y educativas que abarquen los puntos discutidos, con el fin de promover eficazmente la donación y aumentar el éxito de los programas de trasplante.

Cadaver organ donation for transplants is analyzed based on three factors: 1) Religious influence. The Catholic Church, as well as other Christian churches, accept transplants and organ donation as a sign of generosity; 2) An efficient information system for donors and families is necessary for obtaining potential donors; 3) The training of all members of the health team, and their personal views are of great importance to donors and family's decisions. There is a dissociation between religious moral principies and believer's perceptions. Spain, with its National Transplant Organization, has become the main point of reference, having a high rate of organs donation and great credibility. The third factor emphasizes the importance of having well trained professionals with the highest communication skills. Educational and management measures are needed for more successful organ donation and transplant programs.

Acompañamiento del enfermo: Una experiencia de aprendizaje sobre el significado de la enfermedad / Accompanying a patient as an experience to learn the meaning of disease

Background: Due to technical advances and progressive specialization, patient physician relationship evolved from being based on confidence and comprehension to be impersonal and contractual. Aim: To evaluate the change produced in medical students' concept of the meaning of disease, after living an experience of accompanying a patient and their family environment. Material and methods: We used a qualitative research methodology based on participative-action to evaluate an educational method in which a group of third year medical students accompanied a previously selected chronic patient during two months. We performed two focal groups, one previous to the experience and the second one a month later. Additionally, every student wrote a personal narration of the experience. We compared the students' perception of the meaning of disease for the patients and their relatives, before and after the experience. Results: The students confirmed their previous conception about chronic disease, but they also discovered the ways in which some patients and their families overcome their ¡imitations. They pointed out their belief that the physician's comprehension of the meaning of disease for the patient and the family, a need to practice a good medicine and that this knowledge change the physician-patient relationship. Conclusions: This experience was an effective way of ¡earning the meaning of disease, which might be a part of medical student' training, with the corresponding adjustments and changes.

Relación estudiante de medicina-enfermo: visión de los estudiantes / Medical student - patient relationschip: the students' perspective

Background: The relationship between medical students and patients has special characteristics that require to be well understood to prepare both students and tutors. Aim: To learn about medical students' thoughts and experiences once they start working with patients, how do they solve difficulties or problems and their perceptions about professional roles and patient rights. Material and methods: Qualitative study based on semi-structured interviews applied to 30 volunteer third year medical students who were beginning their clinical practice. The answers to open questions were transcribed and then analized and grouped by topics and categories. Results: Helping others was the main motivation to go to medical school. Other reasons were scientific interest and social status. Students felt prepared to communicate with patients. However they felt anxious, stressful and fearful of not being competent or not being able to answer patients' questions. There were some differences between male and female students' feelings. Nevertheless students declared that they had rewarding experiences with patients. They all recognized that patients have the right to reject being treated by students. The answers also showed that the first clinical experiences led to significant changes in their views of the medical profession. Conclusions: Students are aware of their trainee condition, the benefits that they obtain being in contact with patients and of their limitations. Patients must voluntarily accept to be subject of the students' training program and informed consent procedures need to be developed.

Embriones híbridos como fuente de células troncales embrionarias: [editorial] / Hybrid embryos as a source of embrionic stem cells: [editorial]

The HFEA (Human Fertilisations & Embryology Authority) recently accepted to perform research in hybrid embryos generated by transferring human somatic cell nucleus to cow enucleated oocytes, named cytoplasmatic hybrids. The aim is to obtain a source of embryonic stem cells without the use of human oocytes. The arguments for the approval are to avoid the risk of obtaining human oocytes and that these embryos will not be transferred to a female's womb for its development. Those who oppose the technique argue that it is a manipulation of the beginning of life and a disrespect to the dignity of human life because of the destruction of embryos. Nevertheless, the real nature of this new entity has not been established. Biologically it is an embryo with 99 percent of human genome and animal's cytoplasm, not generated from human gametes, it is not a new genome and it will be used only to cultivate stem cells. It does not seem possible to define its nature beyond any doubts. If it were considered as a human embryo it should be respected and protected as every human being. Once more, scientific progress opens new ethical and legal questions that we cannot answer in a definitive way. Researchers are exploring new roads to obtain pluripotential stem cells which should favor the development of innovative therapies. The main objection is the unavoidable destruction of human embryos, although in this case its origin and nature are not clear.

Conflicto de intereses en la práctica clínica: Análisis ético de algunas relaciones con la industria / Conflicts of interest in clinical practice: Ethical analysis of some relationships with the pharmaceutical industry

Sometimes, the prescription practice of physicians can be influenced by factors that are not related to scientific evidence due to the appearance of several conflicts of interest. These conflicts cause social concern and have prompted actions to regulate the ethics of individual and corporative activities related to healthcare. We analyzed the ethical problems involved in the physician-industry relationship. For this purpose, we considered as the main actors related to this problem, the pharmaceutical industry and their marketing strategies, medical doctors and the independence and objectivity that should guide prescriptions and, finally, patients and their right to receive prescriptions based on scientific evidence. From the point of view of the Bioethics principles, Beneficence would not be respected when gifts or other donations received from the industry affect doctor's independence. Non Maleficence principle could be jeopardized if there is an increased risk of treatment failure and finally Justice could be altered if there is a cost increase for either patients or health institutions. As a conclusion, we consider that the presence of conflicts of interest in the relationship of physicians with the pharmaceutical industry is an important ethical problem. In consequence, this group endorses the recommendations of the Chilean Association of Medical Scientific Societies and advices to include ethical guidelines on this topic in the curriculum of medical schools.