[Ethical and philosophical dimensions of decision-making in public health]. / De quelques dimensions ethiques et philosophiques de la décision en santé publique ... et ailleurs.

Decisions in public health, or in individual health care, are taken by people (individuals or collective) for other people (individuals or collective). Human values, that is to say what is connected to Ethics, should be to the fore, de jure. Too often, under the pretext that they refer to subjectivity, they appear only after very many technical considerations. The latter, in a scientist society, are supposed to deserve a claim to objectivity, this being of course illusory. The author, placing himself in the line of Levinas, Ricoeur, and also of Kant, for whom the "What must I do?" is the most fundamental question any human being has to face, develops four reasons which plead for the pre-eminence of ethics as the foundation of decisions in a policy for public health. 1) He reminds us the intangible values, which are on one side uniqueness and universality of mankind, and on the other side the singularity of the human person. 2) He insists on the ethical wreck which threatens the whole health- and healthcare systems. 3) He sets out some results of modern neurophysiological research (AR Damasio's work), joining an intuition of Aristoteles: the decision making process implies two phases: deliberation the aim of which is to list the different possible actions to undertake, then the choice between those actions. Damasio shows that the lack of emotions inhibits the choice, especially when decision implies human values. 4) Finally, he insists, after E. Morin, on the practical and theoretical difficulties in taking a "good" decision, and on what Morin calls "ecology of action". The results of a decision may completely escape from the decision-makers aims, very often for unexpected social and psychological reasons.

[Development of health care networks: ethical and political contexts]. / Le développement des réseaux de soins et de santé: contexte éthique et politique.

The operation of our health care system is in the midst of a major crisis. There is a significantly unacceptable level of health inequities and access to care, high premature mortality rates, lack of a coherent health policy, a weakness in the professional demographic projections, increasing financial deficits, quasi-revolt of professionals, complete disregard for the law (Parliament's vote on the National Insurance's budget)--these are just a few of the symptoms of chaos which have embedded themselves right before our very eyes. This article aims to offer a glimmer of light on this gloomy horizon. It is the first outcome of a new working group which was originally referred to as "les Vignerons d'Uzès", a title which could be seen as lacking substance and has therefore become "The Transdisciplinary Working Group on the Organisation of Health and Care". The group's purpose and objective is to reflect upon the values, practices, regulations, evaluation and what is at stake in the context of our health care system.

Ethical problems in health information systems.

OBJECTIVES: To introduce term and concept of infoethics and to argue on its importance for health information systems. METHODS: To argue about our viewpoint of the dominance of the human component, which has been discussed at an IMIA working conference held in Helsinki, Finland (February 1998) devoted to the evaluation of health information systems. RESULTS AND CONCLUSIONS: Any technology sets a relationship between human beings and their environment, both physical and human. No technology can be seen as merely instrumental. This is especially relevant when dealing with large automatic information systems, developed to contribute to the management and integration of large organizations, such as hospitals. In such a context, the environment is mainly made up of humans. In evaluating such information systems, human factors preside over merely technical factors. Even if satisfying the latter is mandatory, they are never really sufficient. A perfect hard- and software system can be an absolute failure in everyday use. In any information system, the human factor is, of course, human-computer interaction, which always occurs when one person interacts with the machinery. However, in a simultaneous multi-user context, human-human interaction is the main question to tackle. The evaluation of large information systems, such as those found in hospitals, is founded in the whole concept of inter-human relationships which underlie the design and use of the system. Indeed, such an information system predominately appears as a social system, with its psychological, sociological and ethical features.

[Life expectancy in health: major indicators of health in a population]. / Espérances de vie en santé: indicateurs majeurs de la santé d'une population.

The concepts of life expectation, life expectation without disability, are explained. Their importance for defining a health policy and a healthcare policy is emphasized. A concrete example is given: the inequalities in life expectancy without disability follow the same pattern as the inequalities in mortality.

[Security of healthcare data networks used for epidemiological studies]. / La sécurité des réseaux d'informations médicales: application aux études épidémiologiques.

Record linkage, for compiling sameperson records from various source files, can improve the feasibility of epidemiological research using populationbased studies. The question is comply with the European legislation on data privacy and data security. For example, a computerized record hash coding and linkage procedure is described to link medical information within the framework of epidemiological followup. Before their extraction, files are rendered anonymous using a oneway hash coding based on the standard hash algorithm (SHA) function. Once rendered anonymous using the software ANONYMAT, the linkage of patient information can be accomplished by means of a mixture model, taking into account several identification variables. An application of this anonymous record linkage procedure was carried out in order to link medical files on cancer, from 3 hospitals of the French RhôneAlpes region. This application stresses how the use of the ANONYMAT software allows compliance with the legislation on data confidentiality without entailing problems on data availability.

Random reflections on science, art and technique applied to medicine and its evaluation.

Science is aimed at universal knowledge. Art is aimed at action for solving concrete and local problems. Can medical practice therefore ever be a science even when employing important aspects of scientific practice such as precise concepts and vocabulary, and a demand for well-validated facts together with rational reasoning? Evaluation of medical and clinical practices in general has an ambiguous status. According to the domain to be evaluated, it can reach a level of science in providing results of universal value but more often it is closer to art, the results remaining of local interest. There is no strict correlation between the universal-local axis and the practical interest for public health. Epidemiologists should consider these matters very seriously and aim to contribute to, rather than discard, their significance for the advancement of clinical practice.

Information systems evaluation and subjectivity.

This paper claims that, when evaluation of information systems is at stake, it is impossible in most cases to discard human subjectivity in the same way that one cannot discard quality of life when a therapeutic strategy is to be evaluated.

[Representations, discourses and practices about drug substitution with opiates. Apropos of a survey conducted in cooperation with 97 French physicians]. / Représentations, discours et pratiques autour de la substitution médicamenteuse par opiacés. A propos d'une enquête réalisée auprès de 97 médecins français.

In order to analyse the various factors which determine physician's position on the use of opiates in a substitution treatment--as a harm-reducting and heroin dependence treatment tool-, 97 French physicians (i.e. 47 general practioners, 36 psychiatrists, 10 internists, 4 emergency care practioners) answered anonymously 103 closed questions, in presence of a single investigator. Among these 97 physicians, 40 were choosed at random from a list of addiction treatment's practioners, 19 were choosed nominatively for their explicit point of view toward substitution, and 38 were choosed at random from the Herault physicians register. In this latter sample, the survey showed a majority of physicians took an ambivalent position towards substitution, or were favourable without being prescriptors themselves--even though meeting drug users-. General practioners were more favourable to drug substitutes than specialists (50% vs 22%). This practice appeared as legitimate for 70% of physicians; AIDS helped justify this attitude for 26% of the specialists and 5% of the general practioners. Individual or socio-professional factors, the representations of the drug-addict and of his suffering, the perceptions of AIDS contamination risk and the standards of knowledge on the substitution treatments did not differ significatively (p < 0.02) between the groups, determinated according to the expressed practioners point of view toward substitution. Using a method exploring opinion structuration, no description of the typical doctor can be drawn from his position towards substitution. Militant discourses were rare; the main disagreements concerned the status, the negotiation around "the product ... or the medicament" within the drug addict-physician relationship should have. Substitution was considered by some as a mere shift from one object of dependence to another; and to others, as a means of setting up a therapeutic relationship. Ambivalent opinions frequently noticed in the physician's point of view towards substitution appears as a multifactorial phenomenon. Not only does it reveal the physician's difficultie in adapting previous patterns of treatment which are not longer adequate to a critical situation, but it also questions the foundations of the very relationship between the practioner and the drug addict.

[Predictive values of the usual biologic tests for the detection of human immunodeficiency virus infection. Consequences for screening]. / Valeurs prédictives des tests biologiques usuels de détection de l'infection par le virus de l'immuno-déficience humaine. Conséquences pour le dépistage.

This paper tries to review what is scientifically known about the predictive values of biological tests of HIV infection. The epidemiological situation for that infection is characterized by two facts: the very high values of sensitivity and specificity which are close to unity; the prevalence of seropositivity which is on average--at least in western countries--, very low (except for some small specific groups). Under those conditions, Negative Predictive Values are always very close to unity, and the percentage of false negative tests is extremely low. Things are quite different for Positive Predictive Value, which varies very rapidly with very small shifts or uncertainties about specificity and prevalence. In the case when prevalence is very low (general population screening) and at the same time specificity is not excellent (that means < 0.99 or even < 0.995), Positive Predictive Value is very poor and the proportion of false positive tests rather important. Indeed the analysis of scientific literature, using the method of "best synthesis evidence", reveals numerous discrepancies as to the value of specificity among different tests. Figures vary a lot from one study to another. It is not obvious which screening strategies are concerned by the results, which finally entail a strong statistical uncertainty. Finally, the figures published in the literature are given by high standard laboratories. One may fear the tests realized in routine laboratories are less reliable. As a conclusion, let us say that despite their very good quality, the biological tests, when used separately, should not be trusted without strong previous criticism when applied to samples of the general population. Any biological screening should be preceded by a clinical examination, including a precise inquiry, in order to detect people at risk, that means with a high prior probability. Clinical dialogue has moreover another great interest: it allows health consulting and education, and calls for personal responsibility for both seropositive and negative subjects. It is the best choice of method to reach a high preventive effectiveness.

Graduate Programs in Medical Informatics at the Patis Universities.

Most medical schools in France have chairs in Biostatistics and Medical Informatics to coordinate the teaching of these two disciplines both within the regular curriculum of the medical studies and as a specialized teaching. This paper describes the current medical informatics specialized program offered at the Paris Universities. Since 1968 the program has comprised a Master of Science and a Ph.D. degree. At the Master Level, despite several reforms and in-depth program revisions, the curriculum is still organized as a set of modules of 100 hours teaching with a large freedom for the medical faculties to define the contents of the courses and for the students to organize their studies and combine medical informatics, biomathematics and biostatistics training. Since 1990, an intensive one-year full-time course is offered, called Advanced Study Diploma in Medical Informatics, which is strongly research oriented. This program seems a good strategy to form medical informatics specialists who have initially received a broader education in informatics and statistics.

Bladder cancer and black tobacco cigarette smoking. Some results from a French case-control study.

A retrospective study was planned in the Hérault (Mediterranean) region of France where bladder cancer mortality and incidence rates are high. In the present paper, variations in bladder cancer risk according to various smoking-related variables, in particular time of exposure and type of tobacco, are examined. This case-control study with 219 male incident cases and 794 male population controls randomized from electoral rolls was carried out in 1987-89. Trained interviewers obtained information on demographics, dietary habits (coffee, alcohol, artificial sweeteners, vegetables, spices, etc.), occupational exposures and detailed history of tobacco smoking (average number of cigarettes per day, number of years of smoking, age at which they began and/or quitted smoking, use of filter-tip and type of tobacco). The odds ratio (OR) for cigarette smokers versus non-smokers was greater than 5. Results for number of cigarettes daily, duration of smoking and lifetime smoking showed a highly significant dose-response relationship, which was confirmed when these variables were treated as continuous in a logistic regression model. Eighty-eight percent of the smokers used black tobacco. Quitting smoking did not result in a significant reduction in bladder cancer risk. Higher risks were associated with starting to smoke at an early age (OR before age 13 versus after age 21 = 3.42; 95% CI 1.07-10.9) and with black tobacco smoking (OR black versus blond = 1.63; 95% CI 0.73-3.64). Results suggest that black tobacco may be more harmful than blond tobacco and may have an early non-reversible role in bladder carcinogenesis.

Relative importance of risk factors in bladder carcinogenesis: some new results about Mediterranean habits.

In the Mediterranean region of France where bladder cancer mortality and incidence are high, a case-control study with 219 male incident cases and 794 randomized, male population-controls was carried out in 1987-89 to investigate bladder cancer risk factors and more specifically, regional factors. A stepwise logistic regression was applied to the data. This investigation confirms the role of tobacco and of certain occupational exposures in bladder carcinogenesis. There was a significant dose-response relationship with lifelong coffee drinking and alcohol consumption; however the risk estimates were only significantly elevated for the heaviest drinkers. The intake of saccharin was not associated with risk of bladder cancer. Infrequent consumption of carrots, spinach, and marrows conferred an increased risk, suggesting a protective effect of vitamin A. Finally, this investigation results in some new hypotheses. The study of residences and birthplaces has revealed a lower risk for those who have lived in a non-Mediterranean area and a higher risk for those born in a Mediterranean area. These features might be explained by some Mediterranean dietary habits, such as a high consumption of spices (odds ratio = 3.64, 95 percent confidence interval = 2.21-5.98).