Ethical aspects of pediatric home care.

This essay is a discussion of ethical issues that arise in the provision of home health care to technology-dependent children. Different ethical norms, especially with regard to the degree of professional responsibility for outcomes, traditionally have applied to home care and hospital care. In particular, parents generally are expected to do their best, but are not expected to have the same specialized knowledge of risks and benefits with regard to particular interventions as health professionals. When home health care involves the use of advanced medical technology, it strains traditional conceptions of parental responsibilities to care for the health of their children at home. It can also strain traditional concepts of professional responsibilities to care for critically ill children in hospitals. We discuss some of the tensions that arise as medical, psychological, and economic forces lead to the increasing use of high technology in the care of children outside of traditional health care institutions.

Long-term alterations in histology and steroid receptor levels of the genital tract and mammary gland following neonatal exposure of female BALB/cCrgl mice to various doses of diethylstilbestrol.

The relation of the dosage of diethylstilbestrol (DES) administered neonatally to the incidence and severity of genital tract and mammary gland lesions and to the levels of sex hormone receptors was examined using a mouse model for human intrauterine DES exposure. Female BALB/cCrgl mice received various doses of DES (ranging from 5 X 10(-1)-10(-5) micrograms daily for the first 5 days of life) or the sesame oil vehicle alone. In the vagina, at all ages examined (1, 2, 6, and 12 months) cytosolic estrogen receptors are consistently decreased after high doses of neonatal DES (10(-1) and 1 microgram). In contrast, at the same ages, vaginal cytosolic progestin receptors increase after identical doses. In the uterus, the 1-microgram dose of neonatal DES also consistently decreases cytosolic estrogen receptors while increasing cytosolic progestin receptors at 1, 2, and 6 months of age. Histologically, neonatal doses of 5 X 10(-2) micrograms DES result in vaginal lesions at 2 months. With age, this threshold level decreases, implying interaction with an altered hormonal milieu. The uterus shows a sensitivity similar to that of the vagina in regard to the histopathological effects of neonatal DES. The ovary and mammary glands are 10- to 100-fold more sensitive to neonatal DES exposure.

Selective nontreatment of handicapped newborns: a critical essay.

The neonatal intensive care unit is the site of some of the most dramatic technology, complex decision-making and costly activity in the current range of medical institutions. Thus, the decisions made there are particularly visible, and of concern to a society which has increasingly scrutinized and challenged medical practices. Questions of marginal utility and cost-benefit relationships are becoming increasingly prominent. These concerns are heightened by the social and political tensions over issues of the time of initiation of life, quality of life, and assurances of equity for those less well off or handicapped from birth. Robert Weir's book, Selective Nontreatment of Handicapped Newborns, successfully summarizes the current dilemmas and identifies areas of uncertainty and lack of knowledge which cloud the decision-making processes. The book reviews the positions of the major protagonists of the last several years; inevitably, their positions will undergo continuous evolution in response to new data and vigorous political and public policy activity. Weir appropriately identifies the difficulty in arriving at an accurate prognosis as an important and prominent problem in decision-making about defective newborns. The population of surviving, compromised newborns is relatively unfamiliar and their problems remain largely unstudied. Weir's discussion of the desirability of the establishment of Infant Care Review Committees in those institutions which care for defective and handicapped newborns thoughtfully concludes that such committees are, on the balance, desirable. As experience accumulates with Infant Care Review Committees, they should serve the positive purpose of generating open discussion of legitimate disagreements. These committees will provide a forum in which decision-makers can disclose uncertainty, consider alternatives, and receive counsel.(ABSTRACT TRUNCATED AT 250 WORDS)

KIE: Four articles in this issue of Social Science and Medicine are commentaries on Robert F. Weir's 1984 book, Selective Nontreatment of Handicapped Newborns. Kohrman's essay praises Weir for his treatment of the issues involved in discussions about withholding care from some handicapped infants, although Kohrman says that as a pediatrician he is disturbed that doctors might be regarded as potential takers of life. He then identifies the historical, social, and medical factors that have generated the fierce public debate over activities in neonatal intensive care units. Kohrman concludes with a discussion of infant care committees, agreeing with Weir that they could play an important deliberative role in treatment decisions concerning impaired newborns.

Patient characteristics that elicit negative responses from family physicians.

Responding anonymously to a questionnaire asking them to list medical conditions and social characteristics of patients that evoked negative responses, 439 family physicians specified 1,846 medical conditions and 1,519 social characteristics. Of the medical conditions, the largest category (60 percent) represented conditions for which medical treatment offered little or no likelihood of cure or alleviation. Of the social characteristics, the largest category (33 percent) involved behavior that violated the physician's personal norms, even through it had little or no bearing on the patient's health. It appears that the responses accurately reflect the Protestant Ethic value system characteristics of Western Europe and the United States, but this constellation of values is accentuated in physicians by their selection and their professional training. Although negative responses to patient characteristics do not inevitably lead to inferior treatment of the negatively perceived patient, negative feelings might be reduced through changes in both the undergraduate and graduate levels of medical education.

Letter: Risks and benefits of hormonal agents in pregnancy.

PIP: Concern over the possible teratogenic effects of the hormone 17alpha -hydroxyprogesterone caproate (17alpha OHP-C) when given intrapartum to the mother and the possible effects on the cervix and vagina in later life, was voiced in response to a published report, and advocacy of use of this hormone for the prevention of early abortion questioned. In response, the authors share their concern over possible long-term carcinogenic effects as well as possible effects on the hypothalamic-pituitary-gonadal axis, the mammary apparatus, the male genitalia, and psychosexual behavior.^ieng