The ethics of applying new medical technologies

Medical technology itself, including minimally invasive surgery, has no morals; our morality revolves around when and how we use technology. This often involves the individual clinician's assessment of their own abilities and an awareness of two aspects of the technology: its proven efficacy and its safety. Is technology outpacing knowledge? Or do physicians adopt new technologies in a responsible way with good motives? No one knows for sure. Technological progress in medicine has been a mixed blessing. The only ethical element involved in the use of new technologies over which individual medical practitioners have control, is that of user proficiency with the device, procedure, or drug, and the related information they provide to their patients when obtaining their consent for its use. New technologies fall into two broad categories: evolutionary, the most common, and revolutionary, which occur sporadically and may completely change the face of medical care. The learning curve for all new technologies can be steep. So, when should physicians be permitted to use these new technologies without supervision? Who is responsible for setting and monitoring standards for new technologies? With the moving target of medical technological innovation, individual practitioners are primarily responsible for the ethical use of new (to them) technologies. It is physicians' ethics that govern their use of new technologies, being certain that they have the requisite training and experience to use the modality, and that the intervention is safe for their patients. Institutional practitioner credentialing at the local level, despite its faults, will often be the primary control over a technology's use. What will ultimately govern the use of new technologies is the ethics (if they exist) of healthcare institutions and individual practitioners, as well as patient need. This is simply another reason why ethics education is vital for physicians-and other health practitioners and healthcare administrators.     

The effect of pre-existing medical conditions and age on mortality after injury

BACKGROUND: Pre-existing medical conditions (PMCs) have been shown to increase mortality after trauma even after adjustment for the effect of chronological aging. It has been suggested that there is an interaction between injury severity and physiologic reserve, such that diminished physiologic reserve will have an adverse effect on survival at lower injury severity, but that at higher levels of injury severity, physiologic reserve will have much less of an impact. METHODS: Records of 65,743 patients, admitted after trauma, were extracted from the database of the United Kingdom Trauma Network to explore the impacts of age, gender and PMCs on mortality, and modification of these effects by severity of injury. RESULTS: PMCs were categorized as absent (23%), present (23%), or unrecorded (54%). There was an increase in mortality with increasing age at all levels of injury severity. Presence of a PMC was associated with a marked increase in mortality of patients with minor injuries (odds ratio [OR] = 5.9, 95% confidence interval [CI] 4.4, 8.0) or moderate injuries (OR = 2.0, 95% CI 1.4, 2.9), but not in those with more severe injuries (OR = 1.1, 95% CI 0.9, 1.4). The impact of age and male gender were also somewhat more pronounced for patients with less severe injuries. CONCLUSION: These findings support the hypothesis of an interaction between physiologic reserve and injury severity, where PMCs are associated with increased mortality when combined with low to moderate severity injuries, but not when combined with more severe injuries.     

Perioperative genomics

Since the completion of the Human Genome Project 10 years ago, the world has witnessed an incredible progress in human genetics and genomics.(1) This progress was largely driven by the availability of better, faster and cheaper sequencing technology.(2) While it took more than 10 years and more than 1 billion dollars to complete the Human Genome Project,(3-5) an individual in the year 2011 can have his whole genome sequenced within a week for less than $30,000. With cheaper and faster sequencing came a wealth of novel discoveries which makes it timely to review how these newly found insights into the human genome are relevant for perioperative medicine. This article summarises the basics of genetic inheritance, the human genome and modern sequencing methods, as well as genetic variation and how this knowledge may be applied to patient care and research in the perioperative setting.     

The influence of genomics on outcome after cardiovascular surgery

Recent findings in molecular research suggest that the outcome of cardiovascular surgery is at least partly determined by the individual patient's genetic predisposition to react to surgical trauma and extracorporal circulation. The activation of cellular as well as humoral cascades occurs in the perioperative period, and influences the extent of pro- and anticoagulation and pro- and anti-inflammation. These events contribute to the incidence and severity of perioperative ischaemia or organ dysfunction, and thus determine adverse outcomes in patients undergoing cardiac surgery. Candidate genes that are possibly involved in the development of adverse outcomes not only consist of genes relevant to the field of coagulation and inflammation, but also genes functioning in lipid metabolism, ion channels, membrane integrity and others. Genomic variations may prove to serve as future diagnostic tools for the risk stratification of patients undergoing cardiovascular surgery.