Objeción de conciencia y acciones de salud / Conscientious objection in medical actions

Conscientious Objection arises as a response to a regulation that is judged as immoral. Faced with a law that is considered unfair, the citizen can respond accepting it against his will, exercising conscientious objection on a personal level or, collectively reaching civil disobedience or revolutionary violence. This is an old discussion known since ancient Greece. The current enactment of laws that allow actions previously judged as crime, and that contravene medical tradition, reactivated the discussion about such objection. Some people, such as Savolescu, who denies the legitimacy of conscientious objection invoked by doctors, arguing that it is inefficient, leads to inequality and is inconsistent. He proposes that the values of these professionals can be tolerated privately but should not be determinant in the public sphere. These arguments are critically examined, mentioning pertinent answers from theoretical and practical points of view. We highlight that ethics should not differ in public and private spheres and the principles should be the same, but exercised in different fields. It is concluded that conscientious objection is acquiring legitimacy and that it is necessary to reflect on the underlying reasons that lead to invoke it. It should be considered a civilized resource against determinations of power that are considered to be an attempt against personal values and moral integrity.

Sobre el origen y desarrollo del libro Semiologia Médica / Origin and development of the book Medical Semiology

Semiotics and Semiology share a similar etymology and meaning: the study of signs. In Medicine, signs are objective manifestations of disease, as opposed to the subjective nature of symptoms. Medical semiology comprises the study of symptoms, somatic signs and laboratory signs, history taking and physical examination (in English-speaking countries is known as Bedside diagnostic examination or Physical diagnosis). The first edition of Medical Semiology dates from 1987, and new editions appeared in 1999, 2010, and 2017. The book is devoted to semiology proper with clinical orientation. Its origin, however, dates back to 1937, when the University of Chile appointed Dr. Hernán Alessandri (1900-1981), the eminent Chilean medical educator, Professor in Semiology at the Internal Medicine Section of the Hospital del Salvador in Santiago. The authors of the present book served as Dr. Alessandri's teaching assistants for decades. The two-semester course in semiology had a tutorial character: each teaching assistant was assigned five students whom engaged daily in practical activities in the hospital wards for a total of four hours, in addition to a 45- minute lecture on the theoretical aspects of the subject. The 720-page fourth edition of the book brings together teaching method and clinical experience of more than 50 years. The book consists of six Sections: "Cardinal manifestations of disease", "Major clinical syndromes", "History taking and Physical examination", "Clinical diagnosis and the patient-physician relationship", "Laboratory clinical tests and Instrumental exploration of the body," and "Glossary of diseases." In its forty Chapters, a total of 207 issues are described in detail.

¿Tiene cabida, hoy, el "privilegio terapéutico"? / Does therapeutic privilege have a place in modern medicine?

During the last years, bioethical discussion has highlighted the role of the patients' autonomy, being informed consent its particular expression, about decisions that they should make about their own health. The Hippocratic tradition, the deontological positions of the Geneva Declaration of the World Medical Association and numerous codes of ethics in various countries, require that the physician, above all, should ensure patients' health. In this context the discussion on pros and cons for the so-called "therapeutic privilege" are discussed. The "therapeutic privilege" refers to the withholding of information by the clinician during the consent process in the belief that disclosure of this information would lead to harm or suffering of the patient. The circumstances and conditions in which this privilege can become valid are discussed. Special reference is made in order to respect multiculturalism and to the possibility of obtaining advice from health care ethics committees. The role of prudence in the doctor-patient relation must be highlighted. Disclosure of information should be subordinated and oriented to the integral well-being of the patient.

El Sistema de Salud de Chile: una tarea pendiente / The Chilean Health Care System: The task ahead

The most important event in Chilean public health in the XXth Century was the creation of the National Health Service (NHS), in 1952. Systematic public policies for the promotion of health, disease prevention, medical care, and rehabilitation were implemented, while a number of more specific programs were introduced, such as those on infant malnutrition, complementary infant feeding, medical control of pregnant women and healthy infants, infant and adult vaccination, and essential sanitation services. In 1981, a parallel private health care system was introduced in the form of medical care financial institutions, which today cover 15% of the population, as contrasted with the public system, which covers about 80%. From 1952 to 2014, public health care policies made possible a remarkable improvement in Chile s health indexes: downward trends in infant mortality rate (from 117.8 to 7.2 x 1,000 live births), maternal mortality (from 276 to 18.5 x 100,000), undernourished children < 5 years old (from 63% to 0.5%); and upward trends in life expectancy at birth (from 50 to 79,8 years), professional hospital care of births (from 35% to 99.8%), access to drinking water (from 52% to 99%), and access to sanitary sewer (from 21% to 98.9%). This went hand in hand with an improvement in economic and social indexes: per capita income at purchasing power parity increased from US$ 3,827 to US$ 20,894 and poverty decreased from 60% to 14.4% of the population. Related indexes such as illiteracy, average schooling, and years of primary school education, were significantly improved as well. Nevertheless, compared with OECD countries, Chile has a relatively low public investment in health (45.7% of total national investment), a deficit in the number of physicians (1.7 x 1,000 inhabitants) and nurses (4.8 x 1,000), in the number of hospital beds (2.1 x 1,000), and in the availability of generic drugs in the market (30%). Chile and the USA are the two OECD countries with the lowest public investment in health. A generalized dissatisfaction with the current Chilean health care model and the need of the vast majority of the population for timely access to acceptable quality medical care are powerful arguments which point to the need for a universal public health care system. The significant increase in public expenditure on health care which such a system would demand requires a sustainable growth of the Chilean economy.

Algunas amenazas actuales a la confidencialidad en medicina / Some current threats to confidentiality in medicine

Social, technical and legal conditions of the current practice of medicine make it necessary to insist on certain actions and circumstances that may jeopardize the confidentiality of information, offered by patients to their health providers. Therefore, some effects of the current Chilean law are analyzed in this respect, regarding access to data from the clinical record of a patient. Also, the risks of putting certain data on social networking sites are analyzed, as well as some of its effects on clinical practice. The reasons because of mandatory reporting of diseases, meaning danger to public health, is allowed, are mentioned. We also discuss the difficulties involved in managing the results of preventative health screenings and its knowledge by third parties, as well as some possible violations of personal privacy, regarding dissemination of some people health information and its further mention or figuration in mass media. We conclude that it is a must for both physicians and other health team members, to safeguard confidentiality of data to which they have had access, as well as the need to know the relevant law, in order to respect human dignity of patients, each one as a person. We address the attention to the possibility that, practicing in a different way, it could endanger the reliability of clinical records, also impairing the quality of people’s health care.

Sobre el uso de epónimos en medicina / On the use of eponyms in medicine

A distinctive feature of medical language is the use of eponyms or denominations constructed using the names of real or imaginary persons. Some consider this practice as inappropriate, because eponyms are sometimes more a reflection of influence and power rather than the real authorship of discoveries. On the other hand, others consider valid the use of eponyms since they are a part of a scientific domain used to name objects and diseases. The fact is that tradition and use have finally imposed eponyms in medical language and demonstrated its usefulness. They facilitate the communication between peers and are also a tribute to the clinical sagacity and observational skills of their discoverers. A reasonable practice is to favor the use of those classical eponyms that have endured the pass of time due to their clinical importance, specificity diagnostic significance or historical relevance. Moreover, the knowledge of the biography or historical environment of discoverers of signs, syndromes or diseases gives us a historical perspective of medicine and sheds light on the past, evolution and present knowledge and practice of medicine.

Semblanza del Profesor Dr. Hernán Alessandri R / Biographical notes on Professor Hernan Alessandri, M. D

Hernán Alessandri, a renowned Chilean medical educator, was born in Santiago in 1900. He received his medical degree at the University of Chile in 1923. When in 1927 his father, then President of Chile, was sent into exile, he used the opportunity to deepen his medical knowledge in France and Germany. At the University of Chile, he became successively Professor of Clinical Medicine (1932), of Medical Semiology (1937), and Full Professor and Chair of Medicine (1944). At the Hospital del Salvador in Santiago, he organized a Clinical Department exemplary for its discipline, academic environment and dedication to patients and students. He was one of the prime movers for the reform of medical teaching in 1943, created medical residency programs for the training of specialists in 1952, served as Dean of the Faculty of Medicine from 1958 to 1962, and was a founding member of the Chilean Academy of Medicine (1964). He was the first Latin American to be named Honorary Member of the American College of Physicians (1968) and became Emeritus Professor of the University of Chile in 1973. He died in his hometown in 1982. His disciples and friends established in his honor a social and teaching foundation which they named after him. His clinical and diagnostic skills, along with his outstanding intelligence, made him the most brilliant clinician of his time and an exceptional medical educator who has inspired several generations of physicians.

Apuntes sobre la eutanasia / Notes on euthanasia

In the Judeo-Christian tradition, human life is held to be sacred, a semblance of the divine and a gift from God which the individual cannot dispose of at his or her own will. Hence, these monotheistic religions have made of the crime of murder a transgression of God's own commandment not to kill and have extended the applicability of this commandment to the practice of euthanasia and suicide. On the other hand, some non-religious traditions offer plausible reasons favoring euthanasia. This is a delicate matter for physicians, since the Hippocratic tradition forbids euthanasia and because as care-givers they must also bear the psychological, moral and emotional burden of carrying it out. Physicians are trained to preserve life but not to bring it to an end. As human beings, they must always respect the principle of nonmaleficence, and as physicians they must always respect as well the principle of beneficence. It is difficult to accept the fact that ending a human life can be an act of beneficence. In order to differentiate between passive and active euthanasia, the concept of proportionality of medical acts must be brought into consideration. For instance, using high doses of opiates to alleviate pain or withholding the use of an extraordinary method of treatment are not passive acts aimed at ending the life of a terminally ill patient, but medical acts that are reasonable, judicious and proportionate to the condition and irreversibility of a patient's illness. Therefore, so-called passive euthanasia cannot be considered the same as euthanasia. On the other hand, medically assisted suicide is a deceitful form of active euthanasia. The aim of this act is to cause death and the physician is morally responsible for such a death, since he is providing the means for bringing a human life to an end. Many times the desire to die expressed by terminally ill elderly and helpless patients is a request for help and an expression of reproach against a society that allows for their abandonment and neglect.

Ética de la organización de la atención de salud / The ethics of health care organization

Health care organization is not only a technical issue. Ethics gives meaning to the medical profession's declared intent of preserving the health and life of the people while honoring their intelligence, dignity and intimacy. It also induces physicians to apply their knowledge, intellect and skills for the benefit of the patient. In a health care system, it is important that people have insurance coverage for health contingencies and that the quality of the services provided be satisfactory. People tend to judge the medical profession according to the experience they have in their personal encounter with physicians, health care workers, hospitals and clinics. Society and its political leaders must decide upon the particular model that will ensure the right of citizens to a satisfactory health care. Any health care organization not founded on humanitarian and ethical values is doomed to failure. The strict adherence of physicians to Hippocratic values and to the norms of good clinical practice as well as to an altruistic corporative attitude will improve the efficiency of the health care sector and reduce its costs. It is incumbent upon society to generate the conditions where by the ethical roots of medical care can be brought to bear upon the workings of the health care system. Every country must strive to provide not only technically efficient medical services, but also the social mechanisms that make possible a humanitarian interaction between professionals and patients where kindness and respect prevail (Rev MÚd Chile 2004; 132: 388-92).

Diagnóstico de Muerte / The diagnosis of death

This paper undertakes an analysis of the scientific criteria used in the diagnosis of death and underscores the importance of intellectual rigor in the definition of medical concepts, particularly regarding such a critical issue as the diagnosis of death. Under the cardiorespiratory criterion, death is defined as ½the irreversible cessation of the functioning of an organism as a whole¼ and the tests used to confirm this criterion (negative life-signs) are sensitive and specific. In this case, cadaverous phenomena appear immediately following the diagnosis of death. On the other hand, doubts have arisen concerning the theoretical and the inner consistency of the criterion of brain death, since it does not satisfy the definition of ½the irreversible cessation of the functioning of an organism as a whole¼, nor the requirement of ½total and irreversible cessation of all functions of the entire brain, including the brain stem¼. There is evidence to the effect that the tests used to confirm this criterion are not specific enough. It is clear that brain death marks the beginning of a process that eventually ends in death, though death does not occur at that moment. From an ethical point of view, the conflict arises between the need to provide an unequivocal diagnosis of death and the possibility of saving a life through organ transplantation. The sensitive issue of brain death calls for a more thorough and in-depth discussion among physicians and the community at large (Rev Méd Chile 2004; 132: 95-107).