RESUMO
In the context of all of the discussion about "Fletcherian" ethics consultation, we're including this description of ethics consultation for clarity and in deference to the work of John C. Fletcher. It's reprinted from the third edition of Fletcher's Introduction to Clinical Ethics.
Assuntos
Consultoria Ética , HumanosRESUMO
Over the past 25 years fetal reduction has been utilized to reduce the risks of higher-order multiple pregnancies that have resulted from overly successful infertility therapies. The demographics of multiple pregnancy patients have evolved over the past decade, with increasing proportions coming from IVF as opposed to ovulation induction, being older and a higher proportion with donor eggs. Genetic diagnosis prior to reduction is becoming more common and is very safe in experienced hands. For all starting numbers, including twins, reduction to a lower number of fetuses reduces fetal losses, prematurity, and infant mortality and morbidity.
Assuntos
Fertilização in vitro , Redução de Gravidez Multifetal , Gêmeos , Feminino , Humanos , Gravidez , Resultado da Gravidez , Redução de Gravidez Multifetal/ética , Redução de Gravidez Multifetal/tendências , Estados UnidosRESUMO
OBJECTIVE: In the past, our group took the position that we would not provide multifetal pregnancy reduction to a singleton regardless of starting number except for serious maternal medical indications or as a selective termination for diagnosed fetal anomalies. With evidence of increased safety and more women (many aged 40 years or more) asking for counseling about reduction to a singleton, we reviewed our prior reasoning. METHODS: We compared outcomes of 52 first-trimester twin-to-singleton for multifetal pregnancy reduction cases performed by a single operator to twin and singleton data from recent national register studies. RESULTS: Twin-to-singleton reductions represent less than 3% of all cases. Forty of 52 patients were aged 35 years or more, 19 were aged more than 40 years, and 2 were aged more than 50 years (age range 32-54 years). Since 1999, 23 of 28 had chorionic villus sampling before multifetal pregnancy reduction. Fifty-one of 52 reached viability with mean gestational age at delivery of 37.2 weeks. One of 52 patients miscarried (1.9%). Compared with multiple sources of data for twins, the loss rate is lower in twins reduced to a singleton. CONCLUSION: Until recently, multifetal pregnancy reductions to a singleton were rare. Physicians were concerned about the unknown risks of multifetal pregnancy reduction in this situation. They also had moral doubts about the justification to go "below twins." However, physicians know that spontaneous twin pregnancy losses average 8-10%. Also, with experience, multifetal pregnancy reduction has become very safe in our hands. Our data suggest that the likelihood of taking home a baby is higher after reduction than remaining with twins. We propose that twin-to-singleton reductions might be considered with appropriate constraints and safeguards.
Assuntos
Redução de Gravidez Multifetal , Gêmeos , Aborto Espontâneo , Adulto , Amostra da Vilosidade Coriônica , Feminino , Humanos , Idade Materna , Pessoa de Meia-Idade , Gravidez , Redução de Gravidez Multifetal/estatística & dados numéricos , Primeiro Trimestre da Gravidez , Gravidez de Alto RiscoAssuntos
Experimentação Humana/ética , Doença de Parkinson/cirurgia , Placebos , Ensaios Clínicos Controlados Aleatórios como Assunto/ética , Projetos de Pesquisa , Procedimentos Cirúrgicos Operatórios/ética , Enganação , Transplante de Tecido Fetal , Humanos , National Institutes of Health (U.S.) , Doença de Parkinson/tratamento farmacológico , Julgamento Moral Retrospectivo , Medição de Risco , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Estados UnidosRESUMO
We surveyed genetics professionals, patients, and the public about rights to information, to requested services, and to parenthood, posing difficult cases found in practice. In all, 2906 genetics professionals (63%), 499 primary care physicians (59%), 476 North American genetics patients (67%), 394 French patients (51%), 593 German patients (65%), and 988 members of the American public (99%) returned anonymous questionnaires. Results suggest a trend toward increased respect for patient autonomy since an earlier survey in 1985; in most nations more would perform prenatal diagnosis for a couple with 4 daughters who desire a son. A minority (35% in U.S., 14% elsewhere) would perform PND for a deaf couple who want a deaf child, but most (94% in U.S., 62% elsewhere) would do prenatal paternity testing in the absence of rape or incest. About half (51%) would support a woman with fragile X who wants children. The trend to respect patient autonomy was greatest in the U.S. and was least evident in China and India. In general, responses to these cases illustrate a shift away from population or eugenic concerns to a model of genetics focused on the individual.
Assuntos
Aborto Eugênico , Atitude do Pessoal de Saúde , Atitude , Aconselhamento Genético , Serviços em Genética , Internacionalidade , Pacientes/psicologia , Autonomia Pessoal , Diagnóstico Pré-Natal , Análise para Determinação do Sexo , Aborto Eugênico/psicologia , Acesso à Informação , Ásia , Coleta de Dados , Surdez , Pessoas com Deficiência , Europa (Continente) , Feminino , Aconselhamento Genético/psicologia , Aconselhamento Genético/estatística & dados numéricos , Doenças Genéticas Inatas , Testes Genéticos , Humanos , América Latina , Masculino , América do Norte , Paternalismo , Paternidade , Direitos do Paciente , Opinião Pública , Encaminhamento e Consulta , Recusa em Tratar , Estresse Psicológico , Inquéritos e Questionários , Recursos HumanosAssuntos
Doenças Fetais/terapia , Pesquisa Fetal , Terapia Genética , Pesquisa , Medição de Risco , Risco , Aborto Eugênico , Comitês Consultivos , Pesquisas com Embriões , Pai , Aconselhamento Genético , Doenças Genéticas Inatas , Engenharia Genética , Melhoramento Genético , Serviços em Genética , Testes Genéticos , Células Germinativas , Alocação de Recursos para a Atenção à Saúde , Experimentação Humana , Humanos , Consentimento Livre e Esclarecido , Métodos , Seleção de Pacientes , Gravidez , Gestantes , Diagnóstico Pré-Implantação , Diagnóstico Pré-Natal , Política Pública , Técnicas de Reprodução Assistida , Sujeitos da Pesquisa , Alocação de RecursosRESUMO
At this stage, JCAHO [Joint Commission on Accreditation of Healthcare Organizations] site visitors simply want to know how the institution plans to respond to the organization ethics standard. In the near future, however, they will expect data on how ethical issues have been addressed that faced the organization in marketing, billing, managed care contracts, and so on. Pointing to an organizational code of ethics will not be enough. Examples of leadership utilizing the processes of the committee or an appropriate consultant or group, to the ends of education, policy studies, and consultation on specific choices will meet the standard. Organizations that evade or choose not to supply data along these lines will presumably be negatively evaluated. Noncompliance presumably means a risk to accreditation. The message to the clinical ethics committee is a serious one. We must engage in the regional planning and organization needed to provide education and training needed by ethics committees for these two tasks, within the constraints of realism, that is, that these are requirements that are primarily expected of the clinical community and the organizations that provide care to patients.
Assuntos
Comitês de Ética Clínica , Comissão de Ética , Instalações de Saúde , Joint Commission on Accreditation of Healthcare Organizations , Política Organizacional , Defesa do Paciente , Direitos do Paciente , Padrões de Referência , Responsabilidade Social , Pessoal Administrativo , Diretivas Antecipadas , Ética Institucional , Ética Profissional , Pessoal de Saúde , Humanos , Consentimento Livre e Esclarecido , Estados UnidosAssuntos
Criança , Pesquisa em Genética , Terapia Genética , Genética , Experimentação Humana , Pessoas com Deficiência Mental , Coerção , Revelação , Revisão Ética , Ética , Comissão de Ética , Comitês de Ética em Pesquisa , Governo Federal , Doenças Genéticas Inatas , Engenharia Genética , Melhoramento Genético , Células Germinativas , Governo , Regulamentação Governamental , Guias como Assunto , Alocação de Recursos para a Atenção à Saúde , História , História do Século XX , Humanos , Lactente , Consentimento Livre e Esclarecido , Inteligência , Competência Mental , Métodos , Consentimento dos Pais , Seleção de Pacientes , Sujeitos da Pesquisa , Alocação de Recursos , Risco , Medição de Risco , Má Conduta Científica , Controle Social Formal , Justiça Social , Consentimento do Representante Legal , Estados UnidosAssuntos
Humanos , Confidencialidade/ética , Consentimento Livre e Esclarecido/ética , Educação Profissionalizante/ética , Ensino Fundamental e Médio , Genética Médica/ética , Serviços em Genética/ética , Ética Baseada em Princípios , Adoção , Bases de Dados de Ácidos Nucleicos/ética , Diagnóstico Pré-Implantação/ética , Diagnóstico Pré-Natal/ética , Educação , Estruturas Embrionárias , Eugenia (Ciência) , Predisposição Genética para Doença/genética , Suíça , Terapia Genética/éticaAssuntos
Tomada de Decisões , Terapia Genética , Células Germinativas , Pesquisas com Embriões , Eugenia (Ciência) , Liberdade , Pesquisa em Genética , Genética , Regulamentação Governamental , Humanos , Cooperação Internacional , Internacionalidade , Princípios Morais , Pesquisa , Controle Social FormalAssuntos
Comitês Consultivos , Temas Bioéticos , Bioética , Governo Federal , Governo , Política Pública , Aborto Induzido , Síndrome da Imunodeficiência Adquirida , Pesquisa Biomédica , Diversidade Cultural , Atenção à Saúde , Pesquisas com Embriões , Pesquisa Fetal , Transplante de Tecido Fetal , Financiamento Governamental , Liberdade , Objetivos , Regulamentação Governamental , História , Experimentação Humana , Humanos , Princípios Morais , Política , Pesquisa , Controle Social Formal , Valores Sociais , Estados UnidosRESUMO
CONCLUSION: I hope that this response to Scofield's paper has accomplished two goals: 1) it helps put to rest unreal discussion of a "profession" of clinical ethics and 2) it helps to focus on the most important issues raised by Scofield upon which action can be taken. It is true that "ethics is everybody's business" and ethicists must restrain their bias when it comes to the decision-making process. But special knowledge and skills are required to nurture the elements of a clinical ethics program, to unite the efforts of its multitalented members, and to relate the literature of a rapidly growing activity in healthcare to practical projects. The issues raised in the constructive parts of Scofield's paper are an excellent point of departure for debate on how best to shape the education, training, and standards of practice for clinical ethics.