Distributive justice and equity in resource allocation: a temporal analysis of hospitalization costs in indigenous populations in Brazil.

INTRODUCTION: In Brazil, a country of continental dimensions, the health needs of each region have an impact. In this context and the name of the principle of equity, the SUS organizes actions especially aimed at social groups such as the elderly, children, pregnant women, and indigenous peoples. The concept of justice proposed by John Rawls is one of equity, which is essential to this country. METHODS: This is an ecological, descriptive study, which analyzed hospital spending on cardiovascular diseases in the Unified Health System (SUS) among the indigenous elderly population and other ethnicities/colors in Brazil, between 2010 and 2019. RESULTS: Hospitalization costs and fatality rates for indigenous populations and other colors/ethnicities, between 2010 and 2019, were evaluated. A reduction in hospitalization costs for the indigenous population and an increase in other populations was observed throughout the historical series, while there was an increase in fatality rates for both groups. A comparison was made between hospitalization costs and the fatality rates of indigenous populations and other colors/ethnicities according to sex, between 2010 and 2019. It was observed that regardless of sex, there are significant differences (p<0.05) between hospitalization costs and fatality rates, with higher costs for patients of other colors/ethnicities and higher fatality rates for the indigenous population. CONCLUSIONS: Hospitalization costs due to cardiovascular diseases in elderly people from indigenous populations were lower compared to other ethnicities in most federative units, which may suggest an unequal allocation of resources or access for this indigenous population to the SUS. Although there is no strong correlation between spending on hospital admissions and fatality rates, it was found that these rates increased between 2010 and 2019, while spending was reduced.

Communication strategies used by medical physicians when delivering bad news at the Maputo Central Hospital, Mozambique: a cross-sectional study.

BACKGROUND: Physicians' communication with patients and their families is important during both the disease diagnosis and prognosis stages and through the follow-up process. Effective physician communication improves patients' quality of life and satisfaction with care and helps reduce suffering for those newly diagnosed with advanced progressive illnesses. This study aims to identify the communication strategies physicians use in the transition to palliative care and how these professionals perceive their academic and clinical preparation concerning this task. METHODS: A cross-sectional and quantitative study. Physicians providing palliative care at the Maputo Central Hospital, Mozambique, were invited to complete a 17-question questionnaire. This questionnaire was based on a Brazilian adaptation of the Setting-Perception-Invitation-Knowledge-Emotions-Strategy (SPIKES) tool, the P-A-C-I-E-N-T-E protocol, with additional questions regarding socio-demographic details and the integration of "communication of bad news" into hospital training. RESULTS: Of the 121 participants, 62 (51.2%) were male, and 110 (90.9%) were general practitioners, with a median age of 36 years old. They had worked in clinical practice for a median of 8 years and in their current department for three years. The majority of the participants considered that they have an acceptable or good level of bad news communication skills and believed that they do it in a clear and empathic way, paying attention to the patient's requests and doubts; however, most were not aware of the existing tools to assist them in this task and suggested that delivering bad news ought to be integrated into the undergraduate medical course and included in hospital training. CONCLUSIONS: This study adds to our understanding of physicians' strategies when communicating bad news in the context of palliative care at one Mozambique hospital. As palliative care is not fully implemented in Mozambique, it is important to use protocols suitable to the country's healthcare level to improve how doctors deal with patients and their family members.

Equity in health and justice: a look at the Brazilian unified health system (SUS) from the perspective of John Rawls

This study addresses the issue of equity in health and justice from the perspective of public health bioethics, describing the Brazilian Unified Health System (SUS), equating legitimate interests for essential goods, such as health. The conception of John Rawls' theory of justice is "justice as fairness" and has a seventeenth century contractualism tenor. Although it was not conceived specifically for health and marked by the "difference principle", it promoted, in the field of health care, the institution of health systems created on the basis of universal access and equity in the distribution of scarce resources. The principles of the Brazilian Unified Health System (SUS) guarantee access to all levels of care, equality in health care, without distinctions or privileges of any kind, integrity in health care, free of charge, community participation and decentralization, regionalization and hierarchization of health actions and services, which gives the SUS a strong Rawlsian bias. The Brazilian model was built on the principle that health is a right of all and a duty of the State, therefore, it is based on the assumption of universal and equal access to health actions and services for its promotion and recovery.

Este estudio aborda el tema equidad en salud y justicia desde la perspectiva de la bioética de la salud pública, describiendo el Sistema Único de Salud (SUS) brasileño, equiparando intereses legítimos por los bienes esenciales, como la salud. La concepción de la teoría de justicia de John Rawls es la "justicia como equidad" y tiene un tenor de contractualismo del siglo XVII. Aunque no fue concebida específicamente para la salud y marcada por el "principio de la diferencia", impulsó, en el ámbito de la atención sanitaria, la institución de sistemas de salud creados sobre la base del acceso universal y la equidad en la distribución de recursos escasos. Los principios del Sistema Único de Salud (SUS) brasileño garantizan el acceso para todos los niveles asistenciales, igualdad en la atención a la salud, sin distinciones ni privilegios de ningún tipo, integridad en la asistencia a la salud, gratuidad, participación comunitaria y una descentralización, regionalización y jerarquización de las acciones y servicios de salud, lo que da al SUS un fuerte sesgo rawlsiano. El modelo brasileño se construyó sobre el principio de que la salud es un derecho de todos y un deber del Estado, por lo tanto, se basa en el supuesto del acceso universal e igualitario a las acciones y servicios de salud para su promoción y recuperación.

Este estudo aborda a questão da equidade em saúde e da justiça sob a perspectiva da bioética da saúde pública, descrevendo o Sistema Único de Saúde (SUS), equiparando interesses legítimos para bens essenciais, como a saúde. A concepção da teoria da justiça de John Rawls é "justiça como equidade" e tem um teor contratualista do século XVII. Embora não tenha sido concebida especificamente para a saúde e marcada pelo "princípio da diferença", ela promoveu, no campo da assistência à saúde, a instituição de sistemas de saúde criados com base no acesso universal e na equidade na distribuição de recursos escassos. Os princípios do Sistema Único de Saúde (SUS) garantem o acesso a todos os níveis de atenção, a igualdade na assistência à saúde, sem distinções ou privilégios de qualquer espécie, a integralidade na assistência à saúde, a gratuidade, a participação da comunidade e a descentralização, regionalização e hierarquização das ações e serviços de saúde, o que confere ao SUS um forte viés rawlsiano. O modelo brasileiro foi construído com base no princípio de que a saúde é um direito de todos e um dever do Estado, portanto, parte do pressuposto do acesso universal e igualitário às ações e serviços de saúde para sua promoção e recuperação.

Complaints against Physicians in Minas Gerais, Brazil / Quejas contra médicos en Minas Gerais, Brasil / Reclamações contra médicos em Minas Gerais, Brasil

The Regional Councils of Medicine are responsible for the first instance evaluation of ethical-professional complaints against physicians in each federation state. The relevance of the study is based on the importance of evaluating the professional profile of the reported physician, the characteristics of the complaints, and the judging body performance. This study assessed 966 complaints against physicians made to the Regional Council of Medicine of Minas Gerais (CRM/MG) from 2012 to 2017. There was no difference in the average age of the professionals or the period of professional practice. Gynecology, Internal Medicine, General Surgery, and Plastic Surgery comprised most of the complaints regarding medical specialties. The non-specialty reports reached 323 (34%) cases and predominated over the years studied. The number of acquittals was relatively high, in a total of 535 cases, in which the Regional Council of Medicine of Minas Gerais (CRM/MG) considered the complaints unfounded. The hypothesis of a certain corporativism of the CRM did not seem viable since thirty cases received harsher punishments, and among them, eight were removed from professional practice. Some professionals were reported more than once. It is worth noting that the number of recidivists and cases progressively decreased from 2012 to 2017.

Los Consejos Regionales de Medicina son responsables de la evaluación en primera instancia de las denuncias ético-profesionales contra médicos en cada estado de la federación. La relevancia del estudio se basa en la importancia de evaluar el perfil profesional del médico denunciado, las características de las denuncias y la actuación del órgano juzgador. Este estudio evaluó 966 denuncias contra médicos presentadas al Consejo Regional de Medicina de Minas Gerais (CRM/MG) de 2012 a 2017. No hubo diferencias en la edad media de los profesionales ni en el período de ejercicio profesional. Ginecología, Medicina Interna, Cirugía General y Cirugía Plástica englobaron la mayoría de las denuncias relativas a especialidades médicas. Las denuncias de no especialidad alcanzaron 323 (34%) casos y predominaron a lo largo de los años estudiados. El número de absoluciones fue relativamente elevado, en un total de 535 casos, en los que el Consejo Regional de Medicina de Minas Gerais (CRM/MG) consideró infundadas las denuncias. La hipótesis de un cierto corporativismo del CRM no pareció viable, ya que treinta casos recibieron castigos más severos y, entre ellos, ocho fueron apartados del ejercicio profesional. Algunos profesionales fueron denunciados más de una vez. Cabe destacar que el número de reincidentes y de casos disminuyó progresivamente de 2012 a 2017.

Os Conselhos Regionais de Medicina são responsáveis pelas avaliações, em primeira instância, de denúncias ético-profissionais contra médicos, em cada estado da federação. A relevância do presente estudo se fundamenta na importância de se avaliar o perfil profissional do denunciado, as características das denúncias e o desempenho do órgão julgador. O presente estudo avaliou 966 denúncias contra médicos, feitas ao Conselho Regional de Medicina de Minas Gerais (CRM/MG), de 2012 a 2017. Não houve diferença com relação à média de idade do profissional, nem com relação ao tempo de exercício profissional. No que diz respeito às especialidades médicas (tabela 5), as áreas de Ginecologia, Clínica Médica, Cirurgia Geral e Cirurgia Plástica compreenderam grande parte das denúncias. Os denunciados sem especialidade alcançaram o no número de 323 (34%) e predominaram. O número de absolvições foi relativamente alto, num total de 535 denunciados, nos quais o Conselho Regional de Medicina de Minas Gerais (CRM/MG) considerou as acusações infundadas. A hipótese de certo corporativismo do CRM, não pareceu viável, visto que trinta casos receberam punição mais severa, dentre os quais, oito cassações do exercício profissional. Alguns profissionais foram denunciados mais de uma vez. Vale observar que o número de profissionais reincidentes, bem como o número de processos decaiu progressivamente, de 2012 a 2017.

Burnout among Physicians Working in Palliative Care During the COVID-19 Pandemic in Portugal: A Cross-Sectional Study.

INTRODUCTION: Physicians working in palliative care have a greater risk of burnout. Burnout has three dimensions: emotional exhaustion, depersonalization and reduction of personal accomplishments. Burnout is associated with different consequences for the professionals like less professional satisfaction and increase of overall levels of exhaustion. Burnout in healthcare professionals has an impact in the patients with increased probability of clinical erros. In order to monitor the quality of the care it is mandatory to assess overall levels of burnout. This study aimed to determine burnout levels and associated variables of physicians working in the Portuguese national network of palliative care. MATERIAL AND METHODS: A cross-sectional, exploratory and quantitative design was employed and participants were sampled using convenience and snowball technique. The Copenhagen Burnout Inventory was used to determine burnout levels of physicians working in the Portuguese National Network of Palliative Care. The contributions of personal, work and COVID-19 variables were evaluated in three subclasses: work, personal and patient-related burnout. The results obtained enabled the identification of healthcare professionals at risk, comparison with previous results published and to assess the impact of COVID-19 in their non COVID-19 activity. RESULTS: Seventy-five physicians participated. Socio-demographic characterization was conducted and the levels of burnout and determinants were explored. High levels of personal, work and patient-related burnout were present in 32 (43%), 39 (52%) and 16 (21%) physicians, respectively. The majority agreed that COVID-19 had an impact on their activities. Exclusive dedication to palliative care and type of palliative care unit were associated with lower levels of patient and work-related burnout. Weekly physical activity was associated with lower levels of work and personal burnout. Self-perceived health status was associated with lower levels of burnout for all subclasses. CONCLUSION: There was a high level of burnout among physicians working in the Portuguese National Network of Palliative Care. Measures to identify and prevent burnout are necessary in order to protect these professionals.

Introdução: Os médicos que trabalham em cuidados paliativos apresentam um risco mais elevado de burnout. Esta perturbação psicológica carateriza-se por três dimensões ­ exaustão emocional, despersonalização e redução da realização pessoal ­ e está associada a diversas consequências para os profissionais como a diminuição da satisfação profissional ou o aumento dos níveis de exaustão. Ao afetar os profissionais de saúde, o burnout tem também impacto nos utentes, visto causar um aumento da probabilidade de erros clínicos. Com vista a monitorizar a qualidade dos cuidados prestados é fundamental monitorizar os níveis de burnout. O objetivo deste estudo foi o de determinar os níveis de burnout e varíaveis associadas dos médicos que trabalham na Rede Nacional de Cuidados Paliativos em Portugal. Material e Métodos: Estudo transversal, exploratório e quantitativo com amostragem por conveniência e bola de neve. Foi utilizado o questionário Copenhagen Burnout Inventory para determinar os níveis de burnout de médicos que exercem funções na Rede Nacional de Cuidados Paliativos. As contribuições das varíaveis pessoais, laborais e decorrentes da pandemia de COVID-19 foram analisadas segundo três subclasses: burnout pessoal, burnout relacionado com a atividade profissional e burnout relacionado com o utente. Os resultados obtidos permitiram identificar profissionais em risco, fazer uma comparação com resultados prévios na literatura e determinar o impacto da COVID-19 na atividade assistencial não relacionada com COVID-19. Resultados: Setenta e cinco médicos participaram neste estudo. Foi realizada a caraterização socio-demográfica e determinados os níveis de burnout e variáveis associadas. Níveis elevados de burnout pessoal, relacionados com a atividade profissional e para com o utente estavam presentes, respetivamente, em 32 (43%), 39 (52%) e 16 (21%) dos participantes. A maioria considerou que a COVID-19 teve um impacto na sua atividade clínica. A dedicação exclusiva em cuidados paliativos e o tipo de unidade de cuidados paliativos estavam associados a menor nível de burnout relacionado com atividade profissional e para com o utente. A autopercepção de saúde estava associada a menores níveis de burnout em todas as subclasses. Conclusão: Foi observado um elevado nível de burnout nos médicos que trabalham na Rede Nacional de Cuidados Paliativos. São necessárias medidas para identificar e prevenir o burnout nestes profissionais,com vista à sua proteção.

Ethnic-Regional Differences in the Allocation of High Complexity Spending in Brazil: Time Analysis 2010-2019.

The following paper presents as a research problem the ethnic-regional differences in the allocation of high complexity spending in Brazil in an analysis from 2010 to 2019. This is a descriptive research in which a generalized linear model (GLM) was developed to analyze these hospital expenditures with high complexity procedures. The total spending on high complexity procedures in Brazil has increased over the past decade. The study shows that the lowest average expenditures are found in the North and Northeast regions. When comparing the spending between different ethnicities, it was observed that the only decrease between the years 2010 and 2019 was in the amount spent on procedures in indigenous people. The spending on male patients was significantly higher compared to female patients. The highest expenditures, on the other hand, are concentrated in the regions of state capitals favoring the strengthening of hub municipalities. Geographic inequalities in access still persist, even with most states already offering almost all procedures. The Brazilian territory is very heterogeneous and needs to organize its health system by regions, therefore integrated public policies and economic and social development are urgently needed.

Nursing Home Residents Hospitalization at the End of Life: Experience and Predictors in Portuguese Nursing Homes.

(1) Background: Nursing Home (NH) residents are a population with health and social vulnerabilities, for whom emergency department visits or hospitalization near the end of life can be considered a marker of healthcare aggressiveness. With the present study, we intend to identify and characterize acute care transitions in the last year of life in Portuguese NH residents, to characterize care integration between the different care levels, and identify predictors of death at hospital and potentially burdensome transitions; (2) Methods: a retrospective after-death study was performed, covering 18 months prior to the emergence of the COVID-19 pandemic, in a nationwide sample of Portuguese NH with 614 residents; (3) Results: 176 deceased patients were included. More than half of NH residents died at hospital. One-third experienced a potentially burdensome care transition in the last 3 days of life, and 48.3% in the last 90 days. Younger age and higher technical staff support were associated with death at hospital and a higher likelihood of burdensome transitions in the last year of life, and Palliative Care team support with less. Advanced Care planning was almost absent; (4) Conclusions: The studied population was frail and old without advance directives in place, and subject to frequent hospitalization and potentially burdensome transitions near the end of life. Unlike other studies, staff provisioning did not improve the outcomes. The results may be related to a low social and professional awareness of Palliative Care and warrant further study.

Communication of the Diagnosis of Spinal Muscular Atrophy in the Views of Patients and Family Members, a Qualitative Analysis.

INTRODUCTION: Communicating the diagnosis of a genetic and neurodegenerative disease, such as spinal muscular atrophy (SMA), requires a transmission centered on the patient and/or the family caregiver, ensuring autonomy to those involved and strengthening the doctor-patient relationship. OBJECTIVE: Analyzing the communication of the SMA diagnosis from the perspective of patients and family members. METHODS: This qualitative study was developed through semi-structured interviews, via teleconsultation. The analysis was developed by systematically condensing the answers and synthesizing them into four thematic axes (clarification of the diagnosis, communication of the prognosis, affective memory related to the event, and advice to physicians). RESULTS AND DISCUSSION: Twenty-nine patients with SMA and 28 family caregivers of people with this condition, from all regions of Brazil, reported that individualized, clear, honest, and welcoming communication, emphasizing positive aspects, in the presence of family members and with the possibility of continuous monitoring, was important to meeting their communication needs. A lack of empathy, monitoring and guidance, and estimating life expectancy resulted in negative experiences. CONCLUSIONS: The communication needs of patients and family members described during the clarification of the diagnosis and prognosis of SMA predominantly involve empathic factors related to the attitude of the attending physician throughout the evolution of the disease. Future research evaluating other neurodegenerative diseases and the development of research protocols are important to improving communication between physicians, patients, and family members.

Performance of the professional councils concerning 966 complaints addressed to regional councils of medicine (CRM) of Minas Gerais, from 2012 to 2017 / Actuación de los consejos profesionales en relación con 966 quejas dirigidas a los Consejos Regionales de Medicina (CRM) de Minas Gerais, de 2012 a 2017 / Atuação dos conselhos profissionais em relação a 966 denúncias dirigidas ao CRM/MG, no período de 2012 a 2017

Abstract: The study aimed to analyze the actions of the Professional Councils in relation to 966 professional-ethical complaints addressed to the Regional Council of Medicine of Minas Gerais between 2012 and 2017. The number of cases, gender, articles violated of the Code of Medical Ethics and decisions made in the lawsuits were considered. An expressive result was observed in terms of acquittal (535 cases) by the Regional Council of Medicine of Minas Gerais. There was a divergence when the same cases were evaluated by the Federal Council of Medicine, which upheld the acquittal in only 29% of the cases. Due to the methodology applied, it was not possible to go beyond speculation on the subject, being necessary a better analysis of the scientific community on this issue.

Resumen: El estudio tuvo como objetivo analizar las acciones de los Consejos Profesionales en relación con 966 quejas ético-profesionales dirigidas al Consejo Regional de Medicina de Minas Gerais entre 2012 y 2017. Se consideró el número de casos, el género, los artículos violados del Código de Ética Médica y las decisiones tomadas en los juicios. Se observó un resultado expresivo en cuanto a la absolución (535 casos) por parte del Consejo Regional de Medicina de Minas Gerais. Hubo una divergencia cuando los mismos casos fueron evaluados por el Consejo Federal de Medicina, que mantuvo la absolución sólo en el 29% de los casos. Debido a la metodología aplicada, no fue posible ir más allá de la especulación sobre el tema, siendo necesario un mejor análisis de la comunidad científica sobre esta cuestión.

Resumo: O estudo visava analisar as acções dos Conselhos Profissionais em relação a 966 queixas de ética profissional dirigidas ao Conselho Regional de Medicina de Minas Gerais entre 2012 e 2017. Considerou o número de casos, género, artigos violados do Código de Ética Médica e as decisões tomadas nos julgamentos. Um resultado expressivo foi observado em termos de absolvição (535 casos) pelo Conselho Regional de Medicina de Minas Gerais. Houve uma divergência quando os mesmos casos foram avaliados pelo Conselho Federal de Medicina, que manteve a absolvição em apenas 29% dos casos. Devido à metodologia aplicada, não foi possível ir além da especulação sobre o assunto, sendo necessária uma melhor análise da comunidade científica sobre esta questão.

Communicating the Spinal Muscular Atrophy diagnosis to children and the principle of autonomy.

INTRODUCTION: The trinomial relationship between physicians/children/guardians is essential in the process of communicating a disease and its prognosis. OBJECTIVE: Analyzing the exercise of autonomy by this trinomial relationship in communicating the diagnosis of spinal muscular atrophy (SMA).   METHODOLOGY: Caregivers of SMA patients answered a questionnaire containing a structured interview and the Event Impact Scale - Revised. RESULTS: The sample comprised 50 volunteers, 94% of whom were female caregivers. Psychological trauma was predominantly reported when caregivers communicated the diagnosis to children. 22% have a high risk of post-traumatic stress, relating the feeling of unpreparedness in communicating this to the child. CONCLUSIONS: It was identified that the failure in communication is the main factor for negative repercussions on the autonomy of children and their guardians, with self-reported psychological trauma, besides the high risk for post-traumatic stress syndrome.

EMPATIA: A Guide for Communicating the Diagnosis of Neuromuscular Diseases.

INTRODUCTION: Neuromuscular diseases comprise a heterogeneous group of genetic syndromes that lead to progressive muscle weakness, resulting in functional limitation. There is a gap in the literature regarding the communication of the diagnosis of such diseases, compromising the autonomy of patients and families, besides causing stress on the assistant physician. OBJECTIVES: Developing a guide to reduce communication barriers in the diagnosis of neuromuscular diseases. METHODOLOGY: Systematic review, after searching the descriptors ("Muscular Diseases" OR "Neuromuscular Diseases") AND ("Truth Disclosure" OR "Bad news communication" OR "Breaking bad News") in the Pubmed, Bireme, and Scopus websites, and these results were analyzed through narrative textual synthesis. RESULTS: 16 articles were submitted to the final analysis, giving rise to seven steps to support the communication process. These are Empathy, Message, Prognosis, Reception, Time, Individualization, and Autonomy. DISCUSSION AND CONCLUSION: The empathic transmission of the message and the prognosis must accommodate the feelings of the interlocutors with different information needs. In this way, communication planning optimizes the time and individualizes each context, respecting the autonomy of those involved. EMPATIA reflects the bioethical and interdisciplinary analysis of the literature and comes to fill the gap related to the communication of bad news in neuromuscular diseases.

Coping Strategies Used by Patients After Diagnosis Disclosure in the Transition to Palliative Care: A Cross-Sectional Study.

Objectives: The objectives of this study were to identify the coping strategies used by cancer and non-cancer patients with palliative needs, and to verify if there were differences in the coping strategies adopted between sociodemographic groups. Methods: This is a cross-sectional study carried out from September to November 2019, at Maputo Central Hospital, in the units of Medicine, Surgery, Orthopedics, Gynecology and Obstetrics. Eligible patients (n = 94) were included in the study and answered a self-completion scale adapted from the Coping Strategies Inventory by Folkman and Lazarus together with a sociodemographic questionnaire. Results: Our study demonstrates that the most used coping strategies were Social Support, followed by Planful Problem Solving, Escape-Avoidance, and Positive Reappraisal strategies. In addition, significant differences were observed between religious beliefs, with Christians resorting more to coping strategies related to Social Support, Accepting Responsibility and Escape-Avoidance than Evangelicals, and between different levels of education, with greater resort to Social Support, Accepting Responsibility, Planful Problem Solving, and Positive Reappraisal in patients with high education. Conclusions: The results indicate that most of the respondents in this study used more adaptive coping strategies, such as Social Support and Positive Reappraisal, and less avoidant strategies, such as Distancing and Confrontation. There is a need to reinforce positive strategies from health professionals to increase satisfaction, autonomy, and promote patient's quality of life.

Advance Directives: Knowledge of the Topic Among Psychiatrists.

Objective: Advance directives are becoming increasingly important as health technologies evolve. We sought to assess psychiatrists' knowledge of advance directives, as this knowledge is fundamental to the implementation and drafting of these personal documents. Methods: A previously published questionnaire that evaluated the knowledge of medical professors was used. The sample, composed of psychiatrists from Rio de Janeiro, Brazil, originated from a publicly available list. During the search process, the COVID-19 pandemic affected Brazil and the rest of the world, which influenced our methodology and results. Results: A total of 40 psychiatrists participated in the study. The results obtained, although not significant, suggested that psychiatrists with an increased time of practice had more knowledge of advance directives. Nevertheless, less than half of the participants had knowledge about this topic. Conclusion: The number of psychiatrists surveyed indicates the need for further studies on the subject. The influence of the COVID-19 pandemic on this study led to findings such as a change in sensitivity when addressing the topic and greater difficulty in contacting professionals.

The right to be forgotten and COVID-19: privacy versus public interest / El derecho al olvido y el COVID-19: privacidad frente a interés público / O direito ao esquecimento e COVID-19: privacidade versus interesse público

Abstract: Recent studies highlight the importance of digital surveillance to gather individual health information due to the global pandemic caused by the new COVID-19 disease. This paper analyses its legal and ethical implications at the interface between the individual right to privacy and the collective interests of public health. We framed the discussion in law, deontology and utilitarianism. The lasted theories and human rights, especially privacy, are crucial in our argument. Health-derived dilemmas and efforts to solve them, especially by information technologies, bioethics and law, exist at these perspectives' interface. In particular, we analysed the intersection between autonomy, the right to privacy, and the so-called 'right to be forgotten' in the public health context. In other words, we studied the right to obtain from the controller the erasure of health data - a radical means of control over personal data established in Article 17 of the General Data Protection Regulation (GDPR). Given the lack of specifics regarding collection and re-use of such data under the broad scope of public health purposes, implied consent does not address the issue of proportionality. We highlight legal safeguards' insufficiency, suggesting applying the 'right to be forgotten' according to an ethical interpretation.

Resumen: Estudios recientes destacan la importancia de la vigilancia digital para recoger información sanitaria individual debido a la pandemia mundial causada por la nueva enfermedad COVID-19. Este artículo analiza sus implicaciones legales y éticas en la interfaz entre el derecho individual a la privacidad y los intereses colectivos de la salud pública. Enmarcamos la discusión en el derecho, la deontología y el utilitarismo. Estas últimas teorías y los derechos humanos, especialmente la privacidad, son cruciales en nuestro argumento. Los dilemas relacionados con la salud y los esfuerzos por resolverlos, especialmente a través de la tecnología de la información, la bioética y el derecho, se encuentran en la interfaz de estas perspectivas. En particular, analizamos la intersección entre la autonomía, el derecho a la privacidad y el llamado "derecho al olvido" en el contexto de la salud pública. Es decir, estudiamos el derecho a obtener del responsable del tratamiento la supresión de los datos de salud, un medio radical de control sobre los datos personales establecido en el artículo 17 del Reglamento general de protección de datos (RGPD). Dada la falta de especificidades en cuanto a la recogida y reutilización de dichos datos dentro del amplio ámbito de los objetivos de salud pública, el consentimiento implícito no aborda la cuestión de la proporcionalidad. Destacamos la insuficiencia de las garantías legales, sugiriendo la aplicación del "derecho al olvido" según una interpretación ética.

Resumo: Estudos recentes salientam a importância da vigilância digital para recolher informações individuais de saúde devido à pandemia global causada pela nova doença COVID-19. Este artigo analisa as suas implicações legais e éticas na interface entre o direito individual à privacidade e os interesses coletivos da saúde pública. Enquadramos a discussão no direito, na deontologia e no utilitarismo. As últimas teorias e os direitos humanos, especialmente a privacidade, são cruciais na nossa argumentação. Dilemas derivados da saúde e esforços para os resolver, especialmente através das tecnologias da informação, da bioética e do direito, existem na interface destas perspetivas. Em particular, analisámos a intersecção entre autonomia, direito à privacidade, e o chamado "direito ao esquecimento" no contexto da saúde pública. Por outras palavras, estudámos o direito de obter do responsável pelo tratamento o apagamento dos dados de saúde, um meio radical de controlo dos dados pessoais estabelecido no artigo 17º do Regulamento Geral de Proteção de Dados (RGPD). Dada a falta de especificidades em relação à recolha e reutilização de tais dados no âmbito alargado dos objetivos de saúde pública, o consentimento implícito não aborda a questão da proporcionalidade. Destacamos a insuficiência de salvaguardas jurídicas, sugerindo a aplicação do "direito ao esquecimento" de acordo com uma interpretação ética.

The right to be forgotten versus the right to disclosure of gamete donors' id: ethical and legal considerations / El derecho al olvido frente al derecho a revelar la identificación de los donantes de gametos: consideraciones éticas y jurídicas / O direito ao esquecimento versus o direito à divulgação da identificação de dadores de gâmetas: considerações éticas e legais

Abstract: 15. The anonymity of gamete donors in the context of medically-assisted reproduction techniques (ART) and the right of the offspring to know their genetic or biological parents' identity is a controversial and widely debated topic in the scientific literature. The positions on the issue in each country are different. Sometimes they are in opposition to each other even in countries with strong similarities, such as those in the European Union (EU), in the framework of shared ethical values. Although some countries still enshrine the rule of anonymity, there is an undeniable tendency to guarantee the right to know one's origins by creating relevant exceptions or abolishing donor anonymity status altogether. 16. This article offers ethical and legal considerations of whether the so-called 'right to be forgotten' (RTBF) could be extended to include gamete donors' right to remain anonymous. This perspective goes against the general trend, certainly in Europe, of recognizing that offspring born from donor gametes have a right to access information relating to their genetic progenitors. The novel addition is to question whether the General Data Protection Regulation (GDPR) might provide fertile ground for questioning this approach, and effectively support those jurisdictions where anonymity is still possible.

Resumen: 20. El anonimato de los donantes de gametos en el contexto de las técnicas de reproducción médicamente asistida (RM) y el derecho de la descendencia a conocer su identidad genética o biológica es un tema controvertido y ampliamente debatido en la literatura científica. Las posiciones sobre el tema en cada país son diferentes. A veces se oponen entre sí, incluso en países con fuertes similitudes, como los de la Unión Europea (UE), en el marco de valores éticos compartidos. Aunque algunos países siguen consagrando la norma del anonimato, es innegable la tendencia a garantizar el derecho a conocer el propio origen creando las excepciones pertinentes o suprimiendo por completo el estatus de anonimato del donante. 21. Este artículo ofrece consideraciones éticas y jurídicas sobre si el llamado "derecho al olvido" podría ampliarse para incluir el derecho de los donantes de gametos a permanecer en el anonimato. Esta opinión es contraria a la tendencia general, ciertamente en Europa, de reconocer que los hijos nacidos de gametos donados tienen derecho a acceder a la información relativa a sus padres genéticos. La nueva adición consiste en debatir si el Reglamento general de protección de datos (RGPD) podría proporcionar un terreno fértil para cuestionar este enfoque y apoyar efectivamente a las jurisdicciones en las que el anonimato sigue siendo posible.

Resumo 25. O anonimato dos dadores de gâmetas no contexto das técnicas de reprodução medicamente assistida (RMA) e o direito da descendência a conhecer a sua identidade genética ou biológica é um tema controverso e amplamente debatido na literatura científica. As posições sobre a questão em cada país são diferentes. Por vezes estão em oposição umas às outras, mesmo em países com fortes semelhanças, como os da União Europeia (UE), no quadro de valores éticos partilhados. Embora alguns países ainda consagrem a regra do anonimato, existe uma tendência inegável para garantir o direito de conhecer as suas origens, criando exceções relevantes ou abolindo completamente o estatuto de anonimato dos dadores. 26. Este artigo oferece considerações éticas e legais sobre se o chamado "direito ao esquecimento" poderia ser alargado para incluir o direito dos dadores de gâmetas a permanecerem anónimos. Esta perspetiva vai contra a tendência geral, certamente na Europa, de reconhecer que os descendentes nascidos de gâmetas doadas têm o direito de aceder à informação relacionada com os seus progenitores genéticos. O novo aditamento é debater se o Regulamento Geral de Proteção de Dados (RGPD) poderá fornecer um terreno fértil para questionar esta abordagem, e apoiar efetivamente as jurisdições onde o anonimato ainda é possível.

Gender Transition: Is There a Right to Be Forgotten?

The European Union (EU) faced high risks from personal data proliferation to individuals' privacy. Legislation has emerged that seeks to articulate all interests at stake, balancing the need for data flow from EU countries with protecting personal data: the General Data Protection Regulation. One of the mechanisms established by this new law to strengthen the individual's control over their data is the so-called "right to be forgotten", the right to obtain from the controller the erasure of records. In gender transition, this right represents a powerful form of control over personal data, especially health data that may reveal a gender with which they do not identify and reject. Therefore, it is pertinent to discern whether the right to have personal data deleted-in particular, health data-is ethically acceptable in gender transition. Towards addressing the ethical dimensions of the right to be forgotten in this case, this study presents relevant concepts, briefly outlines history, ethics and law of records considering the evolution from paper to electronic format, the main aspects of identity construction and gender identity, and explores the relationship between privacy, data protection/information control and identity projection. Also, it discusses in gender transition the relation between "the right to self-determination", "the right to delete", and "the right to identity and individuality". Conclusions on the ethical admissibility of the 'right to be forgotten' to control gender-affirming information are presented.

Pain management in cancer patients in the main hospitals in Mozambique.

BACKGROUND: Pain is the most feared and distressing symptom in palliative care. In advanced stages of cancer, its incidence is 70-80%. In Mozambique there is little published information concerning to the prevalence, intensity, and pain's management in cancer patients. METHODS: A cross-sectional observational study was conducted between August 2018 and January 2019, in Mozambique's main hospitals, and in the only hospital with an isolated provision of palliative care service. The analyzed data included demographic data, pain intensity and its treatment. The Pain Management Index was used to calculate the adequacy of the analgesia. RESULTS: A total of 294 patients were included. The mean patients' age was 46.1 years old. Concerning to pain, 83.7% of the patients had pain, most of them moderate to severe pain. The prevalence of pain was frequent in women mainly in cervical cancer (84.3%) and in men with Kaposi sarcoma (80%). The main analgesic used for severe pain was paracetamol, and it was used alone in 40.9% of the patients. Morphine was used in 8.1% and adjuvants less than 10%. Pain Management Index was negative for 68.7% of the sample, meaning an inadequate analgesia. Significant differences were found in Pain Management Index levels between hospitals. CONCLUSIONS: The prevalence of pain in the main health institutions in Mozambique is high. Paracetamol was the analgesic most used in severe pain. Further studies are needed to understand the main reasons of patients' suffering.

Burnout Determinants among Nurses Working in Palliative Care during the Coronavirus Disease 2019 Pandemic.

Nurses working in palliative care are at risk of burnout. The Copenhagen Burnout Inventory was used to determine burnout levels of nurses working in the Portuguese national network of palliative care. We evaluated the contribution of personal, work, and COVID-19 variables in three burnout subclasses: personal, work, and patient-related. A cross-sectional, exploratory, and quantitative design was employed and participants were sampled using convenience and snowball technique. An online survey was conducted and 153 nurses participated in our study. Socio-demographic characterization was conducted, levels of burnout and determinants were explored through multiple linear regression models for its three dimensions. High levels of personal, working, and patient burnout were present in 71 (46%), 68 (44%), and 33 nurses (22%), respectively. Most of them agreed that COVID-19 had an impact on their activities. Significant personal and work related burnout factors found were specialization in palliative care, self-perceived health status, unit type, weekly hours of work, and allocation to COVID-19 units. Gender was found to be a significant factor in patient-related burnout. There is a high level of burnout among nurses working in the Portuguese national network of palliative care. Measures for identification and mitigation of burnout are necessary to protect health care professionals.

Defensive medicine and cesarean sections in Brazil.

ABSTRACT: Brazil has a high rate of cesarean sections (CS) that cannot be solely justified by women's clinical conditions; thus, other causes, for example, CS on maternal request and physicians' fear of litigation as possible influencing factors, cannot be overlooked.This study aimed to identify through a survey whether Brazilian gynecologists and obstetricians (GOs) perform defensive CS.In this cross-sectional, descriptive study, a questionnaire was administered. The target population comprised of GOs who were members of premier Brazilian professional associations of gynecology and obstetrics. A total of 403 GOs participated in the survey using an obstetrics questionnaire about litigation and defensive medicine (DM). Statistical analyses were performed on pairs of variables to determine the risk factors of performing CS due to concerns of complications during vaginal delivery and to avoid lawsuits.The mean age of the GOs was 47.7 years who were mostly female (58.3%) and having worked professionally in both public and private sectors (71.7%). Of all participants, 80.6% had been sued or knew an obstetrician who had been sued. The obstetricians who had been sued or who knew a colleague that had been sued exhibited a significantly higher likelihood of performing defensive CS than physicians who had not been sued or did not know physicians who had been sued. The perception of a higher risk of lawsuits against obstetricians influenced the practice of DM and led to a more than six-fold increase in CSs in specialists with this perception compared to specialists who did not believe the presence of an increased risk of litigation in obstetrics existed.The majority of Brazilian GOs perform defensive CS. It is important to consider DM as one of the causes of high CS rates in Brazil and include it in the development of public policies to reduce these CS rates.