Ethical Dilemmas Relating to the Management of a Newborn with Down Syndrome and Severe Congenital Heart Disease in a Resource-Poor Setting.

Decision-making regarding treatment for newborns with disabilities in resource-poor settings is a difficult process that can put parents and caregivers in conflict. Despite several guidelines that have helped to clarify some of the medical decision-making in Ghana, there is still no clear consensus on the specific moral criteria to be used. This article presents the case of a mother who expressed her wish that her child with Down syndrome should not have been resuscitated at birth. It explores the ethical issues at stake in both her misgivings about the resuscitation and her unwillingness to consider surgical repair of an atrioventricular (AV) canal defect. Knowing that children born with Down syndrome are able to pursue life's goals, should our treatment of complete AV canal defect in such children be considered morally obligatory, even in resource-poor settings like Ghana?

Pain as a global public health priority.

BACKGROUND: Pain is an enormous problem globally. Estimates suggest that 20% of adults suffer from pain globally and 10% are newly diagnosed with chronic pain each year. Nevertheless, the problem of pain has primarily been regarded as a medical problem, and has been little addressed by the field of public health. DISCUSSION: Despite the ubiquity of pain, whether acute, chronic or intermittent, public health scholars and practitioners have not addressed this issue as a public health problem. The importance of viewing pain through a public health lens allows one to understand pain as a multifaceted, interdisciplinary problem for which many of the causes are the social determinants of health. Addressing pain as a global public health issue will also aid in priority setting and formulating public health policy to address this problem, which, like most other chronic non-communicable diseases, is growing both in absolute numbers and in its inequitable distribution across the globe. SUMMARY: The prevalence, incidence, and vast social and health consequences of global pain requires that the public health community give due attention to this issue. Doing so will mean that health care providers and public health professionals will have a more comprehensive understanding of pain and the appropriate public health and social policy responses to this problem.

Defining chronic pain ethics.

OBJECTIVE: To identify current issues in the diagnosis and treatment of chronic pain. DESIGN: Focus groups were convened to discuss the current issues in chronic pain care. Commentary was analyzed across focus groups using an interpretivist method of qualitative data analysis. Setting. Focus groups were held in five major US cities throughout the United States. PARTICIPANTS: Key stakeholders working and thinking about the issues surrounding chronic pain, including people with pain, providers, insurance and pharmaceutical industry representatives, law enforcement agents, and advocacy groups. OUTCOME MEASURES: Qualitative data was analyzed to determine if consensus regarding the current issues in the diagnosis and treatment of chronic pain exist. RESULTS: Six major themes emerged regarding chronic pain, all of which contained an ethical component: 1) reducing disparities in access to pain care among the young, elderly, and lower socioeconomic groups, 2) defining quality of care in pain management, 3) the need to train qualified providers and training programs in pain medicine, 4) the need for evidence-based public policy regarding opioid use and diversion, 5) the need to raise awareness about chronic pain as a disease to prevent stigmatization and discrimination, and 6) promotion of multimodal therapies for pain care as a way of diverting attention from opioid abuse problem. CONCLUSIONS: There is nationwide consensus among those holding a stake in the diagnosis and treatment of chronic pain regarding the ethical issues that must be addressed. Raising awareness about chronic pain, improving access and outcomes to quality pain care, and resolving public policy debates about the use of opioids in chronic pain populations are the first steps to ensuring a morally justifiable approach to chronic pain management in the 21st century.