Intended blinders in research.

It could be argued that science is the only generally recognised cognitive authority in the world today. Science is not constrained by frontiers between countries. The art of science is influenced by more factors, how entrenched ideas govern scientific beliefs, also by talent, trends, politics, lobbying, peer-review, priority, conflict of interest etc. Therefore what might have occurred in concealment, is of common scientific interest. An actual example from Denmark is presented showing how research into patients rights and consumer protection has been employed as a technical stumbling-block by health authorities. The authorities problem was certainly a political, not intrinsically a practical medical or scientific one.

The Ombudsman's involvement in ensuring patients' rights.

An analysis has been carried out on the extent and character of patient complaints regarding physicians' conduct, received by the Danish Parliament's Ombudsman during the period 1983-1993. Only a few of the complaints to the Ombudsman are treated completely or partially, because the Ombudsman only examines the administrative handling of the case, and declines to consider the medical opinion. The consequences of the actions chosen by the Ombudsman, regarding ensuring patients' rights, are discussed. In the light of the establishment of more local patient ombudsman systems, there is an ongoing discussion as to just how effective these will be to ensure the legal rights of patients. The possibility of establishing a national patient ombudsman is also discussed.

The legal position with regard to informed consent in Denmark.

Four elements are of importance in the handling of alleged physician faults: the political aims in this field, formal rules, administrative practice by the disciplinary board, and court rulings. However, in general, the law and the guidelines based on it regarding informed consent permit, to a very great extent, the physician to determine what relevant information the patient is to receive, and violation of the principle of informed consent is judged leniently. It is to be questioned whether this satisfies the patient and ensures the right to self-determination, and whether the regulations or the way in which they are applied are in agreement with the political aims in the field. There appears to be a need for political and professional debate regarding this issue.

Some aspects regarding teenage pregnancy in Denmark.

The 'Scandinavian model' is often mentioned as the one that upholds citizens' rights and encourages an opened-minded and honest discussion of problems. This article focuses on unplanned teenage pregnancies in Denmark. During the period 1974 to 1990 the number of live births to women in the age group 15 to 19 years almost halved. During the same period there was only a 20% reduction in the number of legal abortions. The legal abortion rate is considered to be relatively high, and initiatives taken to reduce the rate are elucidated. Special attention is paid to topics such as access to information on contraceptives and the extent to which adolescents use the knowledge they have acquired. Another topic of discussion is the influence of AIDS on younger people with regard to the use of contraceptives. Strategies are suggested that might reduce the number of unplanned teenage pregnancies.

PIP: Denmark's birth rate among adolescents 15-19 years of age was halved in the 1974-90 period, yet the abortion rate in this population declined by only 20%. A Ministry of Health inquiry revealed that only 3 of Denmark's 16 counties had programs in place to reduce the incidence of unplanned adolescent pregnancies and abortion. This phenomenon is considered puzzling given the fact that sex education is compulsory from third grade onward in Danish schools, and teens appear to have higher levels of knowledge about contraceptives than their counterparts in many other developed countries. It is hypothesized that concern about acquired immunodeficiency syndrome has led many Danish teenagers to switch from pill use to the less effective condom. Moreover, only 9% are estimated to be using condoms properly, suggesting an important focus for sex education programs.

Legal aspects of cases of medical malpractice in Denmark.

A survey has been carried out of court rulings during the last decade in cases regarding patients' complaints about alleged medical malpractice. The character of the cases is described, both penal code/disciplinary cases and cases regarding compensation. A number of main themes is evaluated: the availability of case records to the patient; the possibility for patients to choose medical advisers; the lessening of the burden on patients to prove that physicians have been negligent; and the relaxation of the burden on patients to prove causality between the injury and the medical treatment given. These main themes are evaluated over time. The investigation should be seen in the light of the fact that Denmark has recently introduced a patient insurance scheme, and the study will be the starting point for a later evaluation of the importance of this scheme, with particular reference to an improvement in patients' rights.

Dextropropoxyphene deaths in Denmark from the health authority point of view.

All known deaths resulting from poisoning with Dextropropoxyphene (n = 234) in the Municipality of Copenhagen during the period 1982 to 1989 were surveyed. The deaths were found to have occurred in a group characterized by social stress and abuse. A decline was observed in the annual number of deaths after 1985. The influence that the health authorities efforts and debates in the professional press had with regard to this development are discussed. Furthermore, it is recommended that more explicit criteria as to how the cause of death is to be determined in the future should be compiled.

Patients' complaints: the disciplinary system regarding evaluation of physicians' conduct.

The study comprises all complaints which patients have made to the Danish National Board of Health in 1984-1985. The Board had disciplinary powers over physicians and advises the public prosecutor in cases of gross negligence that are to be brought before a court. There were 531 complaints on average per year. The frequency of complaints was 1.0 complaint per 10,000 population. A large part of the complaints concerned cases where no physical harm occurred (45%), and in only a small portion (16%) were there serious injuries. The Board found that negligence had occurred in 21% of the complaints, and 1% of the cases were considered to be gross negligence. There were appeals against 17% of the rulings, and of these 9% were either wholly or partly upheld.

Patients' complaints: some aspects of the evaluation of physicians' conduct by the Danish National Board of Health.

This study comprises all complaints made by patients to the Danish National Board of Health in 1984-1985. All disciplinary cases regarding physicians' conduct are evaluated by the board. A quantitative evaluation was carried out of the 1,062 complaints received by the board in the period under study. Special attention was given to some topics. It is emphasized that adverse outcome termed fortuitous has been narrowed over time, but more investigation is needed, in order to have a more objective foundation from which to determine whether an adverse outcome really is fortuitous or whether it is due to negligence. A central registration of cases of adverse outcome is suggested. The problem of allocating responsibility is very much open to debate, but more adequate case journal keeping is also mentioned. It was surprising that violations of information and consent requirements are often sanctioned very mildly, and more attention to this sphere is appropriate in order to ensure patients' rights. In this connection regular inquiries into patient satisfaction should be considered as a feedback mechanism.

Appeals from disciplinary rulings of patients' complaints regarding physicians' conduct.

In 1984 and 1985 the Danish National Board of Health received a total of 1,062 complaints from patients regarding alleged physician negligence. The board has disciplinary powers over physicians in cases of negligence, and advises the Attorney General in cases of gross negligence which are referred to the court. The investigation found that 17% of the board's rulings were taken on appeal, of these 9% were either wholly or partly upheld. Physicians did not appeal frequently (2%), but their appeals were more often upheld (32%) than was the case in respect of patients' appeals (15% and 4.4% respectively). Evaluation of the cases taken on appeal did not provide support for extending the right to appeal. The consequences of such an extension are, however, discussed in the light of subsequent limitations imposed on the right to appeal and the more well-established and comprehensive provisions for appealing that exist in some neighbouring countries.

The correlation between general disease prevention and prevention of HIV-contagion among adolescents.

A representative group of young persons (N = 745), who used the youth clubs in Copenhagen were asked to fill in a structured questionnaire. A large group of the young had had their sexual debut (N = 367). In respect of this group we found no correlation between prevention regarding general health risk factors vs. prevention against HIV contraction. It is discussed as to whether this difference can be accepted as an expression of the fact that adolescents do not consider the risk of AIDS as something that can affect them. Similarly, current problems in the chain of knowledge, attitude and behaviour in relation to intervention programmes are also discussed, including ethical aspects.

[Contribution of the Medico Legal Council to the National Board of Health's handling of patient complaints about physicians' conduct]. / Retslaegerådets medvirken i Sundhedsstyrelsens behandling af patienters klager over laegers faglige virke.

In 1984 and 1985 the National Board of Health received a total of 1,062 complaints from patients regarding alleged malpractice. The Medico Legal Council submitted an opinion in 100 (9.4%) of these cases. There were only very few cases where there was a real and significant difference between the ruling of the National Board of Health and the opinion of the Medico Legal Council. However, the National Board of Health was clearly more critical in general in assessment of the complaints. It is considered of value, both with regard to the extent of the assessment and also the legal aspects, that it is possible, in some cases, to obtain an assessment of the case by a "second-opinion" from the Medico Legal Council.

Prevention of AIDS: free condoms to drug abusers in the Municipality of Copenhagen.

The slogan "safer sex" was presented in a questionnaire investigation carried out over an interval of 6 months among intravenous drug addicts (N = 116) attending three different outpatient clinics in Copenhagen. Despite this, many of the patients, who were mainly heterosexual and many of whom were HIV positive, continued to practice sexual and injection behaviors which exposed both them and others to HIV infection. Free condoms and advice have been offered as a part of the campaign against AIDS. The initiative was well accepted by the drug addicts and within a period of 6 months there was an increase of 19% in the group which employed condoms. It is concluded that there is still a need for initiatives and research to support the changes achieved in the behavioral pattern of the population.

[Standardized treatment]. / Standardiseret behandling.

Treatment protocols have not been well-defined, and may comprise anything from mere instructions regarding simple procedures to guide-lines for the treatment of the whole course of a disease. The discussion about treatment protocols has continued on since the 70's, and the system has been introduced into the Health Service of a number of countries. Those in favour of the programmes have focused, in particular, on the economic advantages and the advantage of achieving a certain quality of treatment, while those opposing the programmes insist that clinical freedom is at stake. We have found, especially via literature studies, that little knowledge is available as to what extent treatment protocols or case management protocols are employed, e.g., in Sweden and the USA where there have been a number of advocates of these systems. We have only been able to find two evaluation studies of more comprehensive programmes. In these two studies, the total expenditure for treatment was not clearly reduced, and as there were no well-defined parameters for quality of care, it has not been possible to demonstrate any improvement in the quality itself. It is, of course, possible that the discussion in respect of treatment protocols has indirectly had an effect on clinical thought, including those countries where these systems have not been introduced.

Free condoms in youth clubs in Copenhagen.

As a step to limit the spread of AIDS, condoms were supplied free of charge in Copenhagen in youth clubs in connection with personal advice. A representative group of young people (N = 745) and of social workers in these clubs (N = 130) were asked to complete a structured questionnaire. The investigation revealed that the young were well informed about AIDS and its prevention, but despite this, they comprise a relative risk group with regard to the spread of AIDS due to high numbers of partners and poor habits with regard to the use of condoms. The campaign was well received by both the young and the young club social workers. There was an obvious need for a continuation of such a campaign. It is concluded that youth clubs are a good forum for AIDS information.

[The problem of proof in the processing of complaints about alleged medical errors]. / Bevisproblemer i behandlingen af klager over påståede laegefejl.

The processing of patients complaints of alleged medical errors comprises two main elements: the definition of the medical standard and general legal aspects, particularly the submission of evidence. On the basis of laws, chiefly the Health Act, several judicial theories are presented together with empirical studies and usage pertinent to the problem of evidence. It is concluded that there are very few empirical studies but that the instruments of law give wide scope for judgement on issues of alleged medical error.