Placebo surgery in randomised research: possible and ethically justified in some cases

Randomised clinical trials in surgery are relatively rare. There are many problems associated with the comparison of two types of surgical treatment. Comparison of surgical treatment and a non-operative approach is difficult because patient and surgeon are not blinded. In a recent study, the outcomes after arthroscopic lavage or debridement were no better than those after a placebo arthroscopic procedure. This placebo treatment appears ethically justified, because the risks to participants of this study were limited. Placebo surgery may help to resolve longstanding debates about several surgical procedures.     

Breastfeeding: a clinical imperative

Hospital breastfeeding initiation rates (75%) show that most mothers in the United States want to breastfeed and are trying to do so. Even from the very start, however, mothers may not be getting the breastfeeding support they need. Low breastfeeding rates at 3, 6, and 12 months illustrate that women face multiple additional barriers to maintaining breastfeeding. What can we do to help more mothers be more successful? As healthcare providers, we need to be believers that breastfeeding is worth the effort. Perhaps most important for us is to realize that human milk is not simply a food but rather a complex, human infant support system. We can then articulate to families the importance of breastfeeding as a clinical imperative, a preventer of acute and chronic illness and disease. It will take integration, normalization, and mainstreaming of breastfeeding into our culture for acceptance and growth of the practice. Once we assist families in making educated decisions about breastfeeding, we need to provide supportive environments in our hospitals, medical practices, workplaces, and communities that implement the best ways to support breastfeeding. Breast milk is worth the effort, and the time has come to be ardent supporters of mothers and infants and their breastfeeding intentions.     

The research imperative and bureaucratic control: the case of clinical research

This paper examines the development of Research Ethics Committees and explores some of the conflicts of value and role which surround the practice of medical research. The case of medical research on children is discussed as one which raises in an acute form concerns about consent and risk/benefit analysis. The paper draws on a survey of Research Ethics Committees to illustrate their variety of structure and functioning, and to relate current practice to a model of bureaucratic control. Bureaucracy is considered both in its common-sense understanding of officious rule-making and delay, and in its theoretical formulation in terms of specialisation, standardisation, formalization and centralisation of procedures. It is argued that the concept of bureaucracy can aid an understanding of the problems of control over research, as well as providing a model for more informed, consistent and open decision making.     

Risk taking: a supervisory imperative

Beset with job uncertainty and shifting responsibilities, today's health care supervisors are faced with frequent decisions that impact their careers and professional status. To stand pat and avoid change usually involve greater risk than taking chances and may result in job loss. To make bad decisions can also be detrimental. The goal of this article is to encourage one to accept accountability, to avoid the "victim complex," and to make decisions more effectively.     

Front-line training: a health care imperative

Training departments in health care institutions are faced with the problem of providing increased services despite reduced budgets. The increased educational needs are the result of organizational reengineering, mergers and acquisitions, technical advances, and the increasing reliance on less qualified employees. One solution to this dilemma is to make better use of managers and experienced workers as trainers. Keys to success include the ability to convince managers that they will benefit from their expanded roles, and to motivate workers to share their knowledge and skill with their team-mates in a cross-training endeavor.     

Indigenous health: a special moral imperative

The provision of health services to Indigenous people is not perceived by many Australians to be a moral issue. Indigenous health, however, is not only a moral issue, it is a moral issue that deserves special consideration. In many sectors of society, the correct moral path is unclear, but the circumstances of Indigenous health warrant special consideration which policy makers and health care administrators are uniquely placed to render. The settling of Australia was at the expense of Indigenous flourishing. There is little doubt that many of the current poor health outcomes qf Indigenous Australians result from their past impoverishment. We argue that each member of Australian society has inherited a collective moral responsibility, along with the social assets accrued at the expense of Indigenous Australians, irrespective of their personal complicity. Government, as representatives of the people, has a responsibility to repay some of this society's accrued moral debt through the allocation of resources independent of issues of equity.     

Financial imperative: physician relations

At an annual investors' conference in New York City, top not-for-profit health systems outline their challenges and strategies for the future.     

Hospitals and clinicians confront a new imperative: pain management

Treating patients' pain is a new priority for health care providers, spurred by research that dramatically demonstrates the impact pain has on illness and recovery and by pressure from the Joint Commission and patient advocates. Hospitals are confronting the newfound knowledge head-on, setting up pain management programs that offer clinical, rehabilitative and counseling help utilizing traditional and nontraditional methods.