Chemosensory control of surface antigen switching in the nematode Caenorhabditis elegans.

Nematodes change their surface compositions in response to environmental signals, which may allow them to survive attacks from microbial pathogens or host immune systems. In the free-living species Caenorhabditis elegans, wild-type worms are induced to display an L1 (first larval stage) surface epitope at later larval stages when grown on an extract of spent culture medium (Inducible Larval Display or ILD). Before this study, it was not known whether ILD was regulated by the well-characterized, neurologically based chemical senses of C. elegans, which mediate other behavioural and developmental responses to environmental signals such as chemotaxis and formation of the facultatively arrested dauer larva stage. We show here that ILD requires the activities of three genes that are essential for the function of the C. elegans chemosensory neurons. ILD was abolished in chemotaxis-defective che-3, osm-3 and tax-4 mutants. In contrast, chemotaxis-defective mutants altered in a different gene, srf-6, show constitutive display of the L1 epitope on all four larval stages. The ILD-defective che-3, osm-3 and tax-4 mutations blocked the constitutive larval display of an srf-6 mutant. Combining srf-6 and certain dauer-constitutive mutations in double mutants enhanced constitutive dauer formation, consistent with the idea that srf-6 acts in parallel with specific components of the dauer formation pathway. These results taken together are consistent with the hypothesis that ILD is triggered by environmental signals detected by the nematode's chemosensory neurons.

Influence and coercion: relational and rights-based ethical approaches to forced psychiatric treatment.

The dominant rights-based approach to the ethics of coercion in psychiatric treatment guides clinicians in deciding whether treatment should be compelled or the patient's autonomy respected, but provides no guidance across the remaining broad continuum of influence that clinicians exert with patients. The assumptions of the rights-based approach lead to three dichotomous decisions: (1) 'Is the treatment voluntary?'; (2) 'Is the patient competent?' and (3) 'Are the consequence of no treatment dangerous?'. The assumptions of a relational approach lead to ethical guidance across the full range in the intensity and types of influence which may be ethically justified or required in psychiatric treatment. These assumptions are: (1) influence is inherent in the clinical relationship; (2) the relevant factors are continuous and (3) all decisions are subjective. While the rights-approach emphasizes defining competence and developing techniques to predict future patient dangerousness, the relational approach emphasizes patient-clinician responsibilities in ethical relationships and understanding all factors which legitimately bear on the use of influence. An initial list of such factors is offered.

Empathetic maturity: theory of moral point of view in clinical relations.

The article describes a cognitive structural theory of how nurses conceive or understand the personhood of patients. The theory postulates three levels that have the properties of cognitive structures. The third and highest level is held to be a meta-ethical theory of the moral structure of care. For nurses operating with level-III understanding, critiques of justice and care-based ethics are further held to be synthesized within.

Protection and advocacy: an ethics practice in mental health.

This paper reports the findings of investigations into allegations of patient abuse and the implications for policy and practice. These investigations were carried out by a nurse with a background in ethics for the office of Protection and Advocacy for Individuals with Mental Illness (PAIMI), a state agency operating under a United States federal law entitling it to investigate complaints by psychiatric patients. PAIMI uses investigations both to help individuals and to provide an avenue for broader change. There are four steps in the investigation process: (1) definition of the problem; (2) gathering information; (3) synthesis; and (4) addressing the problem. Cases are presented to illustrate the investigation process and identify ethical issues arising in mental health treatment. Among the issues raised are autonomy and forced treatment, deinstitutionalization, bias against the mentally ill, privacy, and surrogate treatment decisions. Resolutions range from providing individual advice to clients or clinicians, to changes in institutional policy and the publication of guidelines for specific situations. The following lessons were learnt from the investigations: (1) tell patients what to expect; (2) pay attention to the process of giving care; (3) allow patients to feel ambivalent about treatment; and (4) work to develop good relationships; underlying every investigation has been a poor relationship.

IRB-identified ethical issues in nursing research.

Ethical issues in nursing research protocols submitted to a School of Nursing institutional review board (IRB) were identified by examining the letters sent to researchers whose protocols required revision or were not-approved. Themes were extracted from the ethical issues and placed into the following categories: The informed consent document, barriers to informed consent, subject benefit, subject risk, confidentiality, and problems with specific populations. The protocols were coded by the researcher's status (student/nonstudent), type of review (expedited/full committee), vulnerability of the population (vulnerable/nonvulnerable), and the type of subject (healthy volunteer/at-risk/patient/family/provider). A total of 157 protocols were examined; of these, 45.9 per cent were approved without requiring revision. Revisions were required in 46.5 per cent of the protocols and 8.3 per cent were not-approved. Problems with the form used to document informed consent were found in 43.3 per cent. The next most commonly identified theme was "information needed" in 30.6 per cent of the protocols, followed up by "inadequate explanation of benefit" in 22.3 per cent of protocols. The nursing research protocols in this study were found to be more vulnerable to ethical problems arising from the relationship between the researcher and subject than from physical harm. It is suggested that nurses give extra care to issues of coercion, deception, and attention to problems uncovered in the research process.

Equipoise: an appropriate standard for ethical review of nursing research?

When using control-group methodologies, the provision of different forms of treatment, which may vary in efficacy, to similar groups of research subjects must be ethically justified. The conventional justification is the existence of a state of clinical equipoise, defined as a lack of consensus among the expert community on the relative efficacy of the treatments. Control groups are justified when the profession does not know which treatment confers more benefit; otherwise, the provision of treatment known to be less effective than other available treatment is unethical. The concept of equipoise was developed to justify clinical trials of medical interventions. Equipoise has proven a durable standard in studies of interventions that confer benefit regardless of the subject's perception. However, equipoise does not apply when a substantive benefit is conferred by the subject's perception. In psychosocial interventions, a subject's experience of the intervention confers benefit and is used to evaluate benefit. Therefore the subject is in a valid position to prefer one treatment over the other and equipoise does not apply.

Policy implications of the biological model of mental disorder.

The current dominant paradigm of mental disorder is that psychopathology is a deviation from normal physiological functioning of the brain. This paradigm is closely allied to the identity theory of mind in philosophy, which holds that mental phenomena are identical with the physical state of the brain. The assumptions of the biological model have policy implications, regardless of the utility or 'truth' of the paradigm, which should be made explicit for the assessment of ethics in mental health policy formulation. The nature of mental phenomena has been debated throughout history, without consensus. Several critiques of the biological model are offered to encourage enquiring scepticism. The policy implications discussed are political conservatism, broadened rationales for forced treatment, utility in managed care, and the use of medical necessity criteria to allocate treatment.

Ethical considerations of video monitoring psychiatric patients in seclusion and restraint.

Video monitoring of psychiatric patients in seclusion and restraint is reviewed from ethical and legal perspectives. Video monitoring invades privacy beyond patient expectations for routine hospital care and has the potential to harm personal dignity. The potential benefit of patient safety through monitoring must be balanced with the potential harm of monitoring to provide ethical justification. Because involuntary monitoring places patients in a position of extreme vulnerability to personal exposure, clinicians are obligated to protect these patients. A case illustrating problems with video monitoring along with recommendations for ethical use of video monitoring are presented in this article.

When the patient causes the problem: the effect of patient responsibility on the nurse-patient relationship.

A positive connection to the patient as a person within a nurse-patient relationship provides the context for ethical treatment. The relationship characterized by caring concern for the patient is also a clinically effective resource. Ethical analysis shows that a nurse's caring and other health care resources should not be allocated based on the degree to which the patient is responsible for the clinical condition. Interviews were conducted with 51 nursing students and nurses about their feelings toward hypothetical patients. The theme of 'patient responsibility for causing the clinical problem affecting the nurse-patient relationship' was identified and responses were categorized according to how the theme was illustrated. The categorization of the responses was validated by two nurse experts. When asked to briefly compare reactions to the vignettes 25 (49%) of the participants connected their feelings towards the patient with their perception of the patient's responsibility.

Clinically based managed mental health care.

Managed care models are on a continuum in terms of the amount of clinical involvement of the managed care agent. Managed care constitutes a fundamental shift in provider-reimburser relations. In the literature problems with managed care are identified and examined in the context of this shifting relationship. Models at three points on the continuum of clinical involvement are reviewed with regard to the identified problems, including two models with full clinical involvement. It is predicted that clinically based models will flourish and replace models with less clinical involvement because full clinical involvement solves many problems associated with other models.

Development of an instrument to measure the cognitive structure used to understand personhood in patients.

Based on a theory of moral regard for personhood, a criterion-related instrument was developed to measure variations in the cognitive structure used to give meaning to personhood in patients. The cognitive structure, called empathetic maturity, has three hierarchical levels. It is measured indirectly through analysis of thought structure. Psychometrics were established in a sample of 41 nurses. Cronbach's alpha was .68. Construct validity was established by correlation with the Defining Issues Test at r = .51. p < .01; with age and education controlled, r = .44, p < .01.

Provider choice: essential to autonomy or advertising gimmick?

Free choice of provider is heralded as a right of autonomy, but the goals of autonomy are better served in today's health care environment when there is informed choice of the care delivery system. The principle of liberty is distinguished from respect for autonomy. Free choice of provider would be demanded only by liberty, except that allocation of health care resources does not meet criteria for the application of liberty. Patients attempting to choose the best practitioner do not have data to support the decision. If data were available, access to these superior practitioners would become an allocation problem. A mythology of the wise practitioner fosters the concept of provider choice as a personal judgement about clinical knowledge. The emerging trends of collaborative care, standardization of practice guidelines and diversity of delivery systems among reimbursers create a situation where a patient's autonomy to choose goals for treatment is respected through the choice of delivery system.

Ethical cautions in the use of outcomes for resource allocation in the managed care environment of mental health.

Increasingly, resources are being allocated through competitive contracting based on outcome data. This context for outcome research renews ethical concern about the nature of outcome data in the field of mental health. The epistemology of mental illness creates special concerns regarding outcome measurement. Ethical cautions specific to six types of outcome measurement are reviewed: utilization, clinician reports, patient reports, objective measures of diagnostic entities, objective measures of functioning and multifactor research. Brief guidelines are offered for addressing ethical cautions. Also discussed are the difficulty in defining good outcomes and a social obligation to future generations that may be better addressed through process measurements.

A treatment-team model of managed mental health care.

Many models of managed care have been criticized as inflexible and intrusive, including those in which decisions about level of care are made by third-party reviewers, in-house staff, or other clinicians not involved in the patient's treatment. The treatment-team model of managed care, which has been implemented in the emergency psychiatric service of a midsized, non-profit community hospital in a metropolitan area, addresses these criticisms. Major features of the model are in-person assessment by a clinician who acts as the managed care agent; immediate accessibility of this clinician; referral services with a broad range of intensity, including crisis intervention; and participation of the managed care clinician on the treatment team. The advantages of this model include the incentive to employ qualified managed care clinicians and an increased ability to provide individualized services. Limitations of the model include the diffusion of decision-making power within the treatment team, the potential for overuse of emergency services by primary providers, and the potential for the managed care agent to lose decision-making power due to personal or systems issues.

The ethical considerations of managed care in mental health treatment.

1. Managed care as a cost-cutting technique is becoming increasingly prevalent; one reason for its growth is the increasing number of people covered by health maintenance organizations and preferred provider organizations. 2. Ethical areas of concern raised by managed care include restrictions on patient autonomy of choice of treatment and treatment site; relationship between the nurse as a managed care agent and the patient; patient responsibility in treatment decisions made through managed care; and denial, curtailment, or alteration of access to treatment based on compliance. 3. Managed care is a tool to conserve and equitably distribute care resources. To be certain that managed care performs this function equitably, the profession must continue to examine managed care in the light of biomedical ethics.

Populations vulnerable to the ethics of caring.

This paper presents the argument that any patient population which can be perceived as being culpable for the pain they are in is vulnerable to the ethics of caring. First, both the ethics of caring and justice are reviewed, and the inadequacies of each, with regard to nursing, are discussed. The problems of the ethics of caring are demonstrated empirically and with interviews done by the author. Then the impacted populations are reviewed. The conclusion presents an emerging vision of synthesis between the moral concepts of caring and justice.

Controversies in nursing ethics: a historical review.

The author critiques the dialectic between justice-based ethics and an ethic of caring from a historical perspective (by analogy with the dialectic between agape and friendship). Justice-based ethics have been problematic for nursing because of the decontextualized approach. The ethic of caring is problematic because caring, being contextual, is particularistic and therefore can be based on morally irrelevant factors, such as liking. There is a tradition of writing which seeks to reconcile the particularistic obligations of friendship with the moral duty to all others equally. Ideas from the following authors are reviewed for relevance to nursing: Aristotle, Aelred of Rievaulx, Augustine, John Cassian, Cicero, George Berkeley, Immanuel Kant, Michel de Montaigne, Jeremy Taylor and Max Weber. The authors concludes by noting that both sides of the dialectic are synthesized in the lived experience of individuals. A synthesis in thought is called for on this basis.