Ethics in psychiatric research : resources for faculty development and resident education.

Controversy has arisen in recent years about the participation of psychiatric patients in questionably ethical research protocols. Consequently, academic psychiatrists have been called upon to enrich their understanding of the ethical aspects of research and to teach residents more intensively about these issues in scientific methodology. Toward these ends, the authors have assembled an extensive resource listing in the area of psychiatric research ethics. Articles were identified through MEDLINE and BIOETHICS LINE computerized searches and the authors' review of relevant literature through 1996. Emphasis was placed on those pieces with special historical value, empirical studies, and papers that provide background on the current controversies in psychiatric research ethics. The references were organized into five logical categories. Based on the resource review, the authors briefly discuss areas related to research ethics that merit greater attention in academic psychiatry.

Attitudes of consultation-liaison psychiatrists toward physician-assisted death practices.

The objective of this study was to investigate the views of consultation-liaison (C-L) psychiatrists on assisted-death practices. A 33-question anonymous survey was distributed at the Academy of Psychosomatic Medicine Annual Meeting in November 1995. The instrument explored perceptions of acceptability of assisted death in six hypothetical patient situations as performed by four possible agents. The response rate was 48% (184 conference attendees participated, i.e., completed and returned the surveys). With little variability, the respondents were unwilling to perform assisted death personally and also did not support assisted death as performed by nonphysicians. The respondents were somewhat more accepting of referral or other physicians' involvement in such practices. Assisted death was viewed differently than withdrawal of life support. Several variables were analyzed for their influences on the views expressed. The C-L psychiatrists in this study expressed opposition to assisted death practices. Their views varied somewhat depending on the patient vignette and the agent of death assistance. The authors conclude that C-L psychiatrists may wish to develop their present therapeutic and evaluative role in patient care to alleviate suffering, without hastening patient death.

Internal medicine, psychiatry, and emergency medicine residents' views of assisted death practices.

BACKGROUND: Although studies have revealed conflicting attitudes within the medical community regarding assisted death practices in the United States, the views of current resident physicians have not been described. OBJECTIVE: To investigate the perspectives of residents from 3 medical specialty fields regarding the acceptability of assisted suicide and euthanasia practices as performed by 4 possible agents (the resident personally, a referral physician, physicians in general, or nonphysicians in general) in 6 patient scenarios. METHODS: An anonymous survey exploring responses to 6 patient vignettes was conducted with a convenience sample of all residents in the internal medicine, psychiatry, and emergency medicine training programs. RESULTS: A total of 96 residents, 72% of those asked, participated in this study. Overall, residents expressed opposition or uncertainty regarding assisted suicide and euthanasia. The residents were disinclined to directly perform such practices themselves and did not support the conduct of assisted suicide practices by nonphysicians. Respondents were somewhat more accepting of other physicians' involvement in assisted death activities. Conflicting views were expressed by residents, with emergency medicine residents more likely to support assisted suicide practices in 4 of 6 patient vignettes than either internal medicine or psychiatry residents. Residents who reported being influenced by religious beliefs (21 respondents [22%]) did not support assisted death practices, whereas those influenced by personal philosophy (74 respondents [77%]) expressed less opposition. CONCLUSIONS: This study explores the uncertainty and differing views of residents from 3 fields about physician-assisted suicide practices. Study findings are considered within the larger literature on clinician attitudes toward assisted suicide and euthanasia.

Clinical ethics teaching in psychiatric supervision.

Supervision of psychiatric residents provides a natural context for clinical ethics teaching. In this article, the authors discuss the need for ethics education in psychiatry residencies and describe how the special attributes of supervision allow for optimal ethics training for psychiatry residents in their everyday encounters with ethical problems. Ethical decision making in clinical settings is briefly reviewed, and a 6-step strategy for clinical ethics training in psychiatric supervision is outlined. The value of the clinical ethics supervisory strategy for teaching and patient care is illustrated through four case examples.

Early vascular grafting to prevent upper extremity necrosis after electric burns: additional commentary on indications for surgery.

Early vascular grafting has been used to reestablish circulation to the hand in the treatment of electric injuries of the wrist with arterial damage. Since 1972 this therapy has yielded good results by preventing necrosis of the injured hand and by helping to maintain function. However, the indications and timing for performing this operation still are poorly defined. The surgeon is faced with the difficult task of determining whether the injury is severe enough to affect distal circulation and thereby lead to necrosis. The lack of reliable clinical signs is chiefly responsible for this difficulty; however, the potential for delayed thrombosis of vessels complicates the problem. In this article, indications for early vascular grafting in an electrically injured wrist are discussed based on recent clinical experience, with emphasis on the use of arteriography. A case history involving electric burns of both upper extremities is presented as an illustration.

Transplantation of anastomosed vascular allomentum and split thickness autogenous skin grafting for repair of deep electrical burns of the wrist.

The use of allomentum to replace automentum or skin flaps in treating 3 patients with severe electrical burns of the wrist is discussed, as are the specific advantages and disadvantages, and the prospects for clinical use of the technique.

Regeneration of full layer necrosis of the skull following high voltage electrical injury.

Scalp and skull necrosis often follow high voltage electrical injury to the head. Classically reconstruction of the scalp and skull is performed after sequestration of the necrotic bone. The relatively frequent complication of epidural infection, however, detracts from this approach. As an alternative we have attempted to induce regeneration of devitalized bone by covering it with a vascular tissue flap. A typical patient is described in this report with results which indicate that at least partial regeneration of the necrotic tissue can occur, thus one-stage management of such wounds is possible.

Long-term reversible suppression of oestrus in bitches with nafarelin acetate, a potent LHRH agonist.

Adult cyclic beagle bitches were treated for up to 18 months with nafarelin acetate via subcutaneously implanted osmotic pumps, starting during the first week of a pro-oestrous vaginal discharge. The imminent ovulation appeared to be unaffected by treatment, but doses of 8 or 32 micrograms analogue/day reduced the integrated luteal progesterone values. No new oestrus was detected in 3 bitches during 18 months of treatment with 32 micrograms/day, which resulted in mean plasma levels of 0.4 ng analogue/ml. A return to oestrus was observed in all 3 bitches between 3 and 18 weeks after cessation of treatment: 2 of the bitches mated at those times and produced normal litters. Another 2 bitches were similarly treated with 32 micrograms analogue/day; they were mated at the oestrus at start of treatment and dosing was continued for about 63 days. One of the bitches conceived and produced a normal litter. Nafarelin acetate treatment begun during anoestrus resulted in an induced heat 1-2 weeks after the start of treatment. The induced heat consisted of pro-oestrous vaginal discharge, oestrous vaginal cytology, and ovulation (judged by increased circulating levels of progesterone). Three bitches mated at the induced heat and treated for the normal duration of gestation did not litter. Nafarelin treatment of 3 bitches before puberty did not induce signs of oestrus and prevented the occurrence of oestrus through 18 months of treatment. The first oestrus in these bitches occurred 3.5-4 months after cessation of treatment, but mating at that time did not result in pregnancy. These studies have established the feasibility of and dosage requirement for the use of the LHRH agonist as a contraceptive in the bitch.

Early vascular grafting to prevent upper extremity necrosis after electrical burns. Commentary on indications for surgery.

Early vascular grafting is the only effective form of treatment for electrical burns of the wrist which are severe enough to impair blood flow to the hand. Failure to appreciate the significance of early changes in blood flow and to take prompt appropriate action may result in the irreversible loss of blood supply and subsequent amputation. This report analyses the problems encountered in six patients where the early signs of impaired blood flow were not appreciated and amputations were subsequently required.

Dose-response studies on male reproductive parameters in dogs with nafarelin acetate, a potent LHRH agonist.

Adult male beagle dogs were administered daily subcutaneous injections of either 0.5 or 2.0 micrograms/kg of a potent LHRH agonist, nafarelin acetate, for 44 days. Although there was a rise in the circulating levels of the gonadotropins and of testosterone following the early injections of agonist, continued treatment caused a marked decline in acute response and basal levels of both LH and testosterone and smaller decreases in the acute FSH response. The decline in LH and testosterone was accompanied by decreases in testicular volume, ejaculated sperm count, sperm motility, ejaculate volume, and duration of ejaculation. The decline in these parameters was more rapid at 2.0 micrograms/kg than at 0.5 micrograms/kg. The profile of responses to 2.0 micrograms/kg could be superimposed on that previously shown for the injection of 10.0 micrograms/kg. At the end of treatment, prostate weights were 36% and 68% of vehicle-treated controls for high- and low-dose animals, respectively. Spermatogenesis was absent in the testes of all agonist-treated animals. Over the dose range tested, the dose-response on all parameters was characterized by a slower evolution to the same maximal effect, rather than by a partial effect. If these data can be extrapolated to man, they would suggest that administration of higher dose levels of LHRH agonists than presently reported should be explored.