Beyond the 'embryo question': human embryonic stem cell ethics in the context of biomaterial donation in the UK

Discussion about the ethics of human embryonic stem cell (ESC) research in the UK tends to be dominated by the divisive and potentially intractable issue of the moral status of the embryo. This can have the effect of silencing or marginalizing other concerns, especially in the context of public engagement with science in this field. One such area of potential public concern is the donation of oocytes and embryos to stem cell research. Contemporary research on the views of donors and potential donors about a wide range of biomaterials, from solid organs to gametes and bone marrow, is reviewed and used to illustrate the range and types of ethical concerns articulated by this important group of stakeholders. Attitudes to donation are found to vary according to the type of tissue being donated or collected, the purpose for which donation is being sought and the nature of the recipient of the donation. Pertinently, attitudes towards donating oocytes are found to differ in some respects from donation of embryos or fetal tissue. The implications of these findings for ensuring ethically robust informed consent and publicly acceptable sourcing of human biomaterials for stem cell research are then considered.     

Education in ethics

Ethics is the system of thought that analyzes moral judgments. Among the key features of ethics are: (1) it must be translatable into moral action; (2) it is a public system rather than a private activity, and no one can act morally without reference to other individuals; and (3) the fundamental ethical principles underpinning medical ethics are those of society in general. Among the purposes of education in ethics are the development of consistent, critical, and reflective attitudes to ethical decision-making; increasing awareness of ethical dilemmas in one's own practice and that of others; and reinforcement of best practices in clinical and research governance. Ethics is the system of thought that analyzes moral judgments. Among the key features of ethics are: (1) it must be translatable into moral action; (2) it is a public system rather than a private activity, and no one can act morally without reference to other individuals; and (3) the fundamental ethical principles underpinning medical ethics are those of society in general. Among the purposes of education in ethics are the development of consistent, critical, and reflective attitudes to ethical decision-making; increasing awareness of ethical dilemmas in one's own practice and that of others; and reinforcement of best practices in clinical and research governance.     

Is continuing medical education under suspicion of corruption? Contribution to the discussion by the Committee for Quality Preservation of the Swiss Society of Gynaecology and Obstetrics

The requirements laid down by law and by the medical profession itself with regard to continuing medical education have recently been tightened. The cost of good training is high, both in time and money. Sponsoring, especially by the pharmaceutical industry, has helped to keep costs down for individual participants. The question of a tariff system for the payment of compulsory training is now being raised. Rates have been set to ensure that, in the future, indirect costs are covered. In the event of a full tariff-based payment of costs being introduced, various disadvantages could be expected both for participants and the quality of the training. Changes in Swiss criminal law and the new medicines act do not forbid sponsoring, but they do call for rules of professional ethics and of personnel law in public hospitals governing behaviour in respect of funding by sponsors. Various sponsoring models are conceivable with differences in allocation to organizers, individual participants or distribution via a pool system. There are strong arguments in favour of continuing the existing practice of mixed funding by participants and sponsoring, provided that it is subject to certain rules of transparency. What is lacking to date is a political decision on the issue of funding for continuing medical education.     

The foundations and the development of modern

Modern bioethics is based on a pluralistic and multidisciplinary approach, deriving its sources from medicine, biology, philosophy, law, theology, social and behavioral sciences, and history. The moral foundation of modern biomedical ethics is based upon four prima facie principles: respect of autonomy, beneficence, nonmaleficence, justice. This approach, however, has been seriously critisized and challenged. A wide range of issues is discussed and debated in biomedical ethics. Several causes have intensified the recent flourishing of medical ethics: The enormous advancements in scientific and technological knowledge; the intense and widespread interest in bioethics by professionals as well as by the public at large; and the wide sociocultural and economic changes in western society, and in the conduct of medicine. The objectives of clinical medical ethics is outlined in the article.     

Reminiscences on learning about morals and ethics in biomedicine

Learning about ethics requires a knowledge of moral philosophy. Until recently, scientists paid little attention to moral philosophy or ethics during their training. Many of them, and especially biologists, made their first acquaintance with these classic topics as they began their PhD. Their learning depended on whether their Professor or Supervisor was knowledgeable in these disciplines, even if self-trained. Medical students were obviously more aware of the ethical aspects of their work. As a dedicated scientist, I had undertaken a PhD in developmental genetics of mouse embryos which demanded injecting hormones, operations, autopsies, and examining blastocysts and fetuses for imbalanced chromosomes. Stress laid on ethics and moral philosophy by my professor, Conrad Waddington in Edinburgh University, proved enormously helpful as I moved to human IVF, stem cells and preimplantation genetic diagnosis and maturing oocytes in vitro. No-one else was interested, neither in these topics, nor their ethics. This situation changed as I telephoned Patrick Steptoe, inviting him to join us. His brilliant laparoscopy was essential as we worked together on human IVF. We helped establish an Ethical Committee to guide us. Today, IVF scientists and clinicians are deeply aware of their ethical responsibilities to their patients. They face a challenging future as new developments transform their field of study.     

Prenatal diagnosis of single-gene disorders

Genetic disease can occur due to imbalance of whole chromosomes, smaller chromosome microdeletions or duplications, or at the single-gene level where even a single base change can cause significant disease. This review focuses on the methods available to achieve genetic diagnosis of a fetus in pregnancy, both in the context of a family history of a known disease-causing gene variant and where there is clinical suspicion of a genetic disorder based on ultrasound findings. The indications for rapid trio whole exome sequencing in the prenatal setting will be considered. Until relatively recently, genetic testing of a fetus invariably required invasive procedures to sample fetal tissue, with associated risk of miscarriage. However, non-invasive methods of achieving prenatal diagnosis by sampling fetal DNA present in maternal blood have undergone considerable development. Current applications of invasive and non - invasive prenatal testing are discussed with clinical case studies.     

Argument-based medical ethics: a formal tool for critically appraising the normative medical ethics literature

Although there are critical appraisal tools for other genres of the medical literature, there currently is no formal tool for physicians to use in their critical appraisal of the normative medical ethics literature. We present a formal assessment tool for the critical appraisal of the normative medical ethics literature that incorporates the intellectual standards of argument-based medical ethics and evidence-based medicine. We draw on the intellectual standards of argument-based ethics, ethical analysis and argument, and the literature on evidence-based medicine. The tool involves 4 questions about normative medical ethics papers: (1) Does the article address a focused ethics question? (2) Are the arguments that support the results of the article valid? (3) What are the results? (4) Will the results help me in clinical practice? Obstetrician-gynecologists can use this tool to appraise the normative literature of ethics in obstetrics and gynecology formally.     

Ethical dilemmas in women's health in under-resourced settings

Ethical decision making in women's health presents a series of unique challenges that are exacerbated considerably in under-resourced settings. Severe constraints on both autonomy and resources highlight limitations of principle-based ethics for addressing ethical dilemmas. Other useful ethical "tools" are considered in the context of 2 cases that emphasize the challenges to ethical decision making in under-resourced settings. The cases confront traditional notions of patient autonomy, highlight pervasive issues with regard to allocation of resources, and demonstrate the difficulties encountered in the careful application of medical ethics.     

Recht der Sterbehilfe in der BRD

Legislation is supposed to facilitate responsible medical decisions by doctors in the context of terminal care, whereas legal uncertainty often leads to an extensive “medicine of justification” that contradicts medical ethos. In contrast to a widespread misinterpretation, the termination or limitation of life-supporting measures (e. g. parenteral nutrition) is not a forbidden active euthanasia, but an unprohibited passive euthanasia, if the patient has expressly asked for it, if he has ordered to do so within a valid advance directive in case of his inability to decide, if this is according to his presumed will or if the dying process has already begun. Whereas active euthanasia remains a criminal act in Germany, assisted suicide is not prohibited, even though it is rejected by the majority of doctors for reasons of occupational ethics.     

Therapie der Endometriose unter Berücksichtigung der Aktivitätsgrade

Active proliferating implants in endometriosis cause pain by inducing biochemical and mechanical mechanisms. Medical and/or surgical treatment is indicated. Regressive and inactive foci induce no mechanisms which cause pain, therefore therapy is not necessary. In contrast, even in inactive endometriosis surgery can be beneficial when fibrosis and scars secondary to the disease cause pain mechanically. Severe stages of endometriosis cause sterility by mechanical disturbance of the reproductive organs. Endoscopic surgery is an effective treatment. Some data in the literature demonstrate that treatment of mild endometriosis – surgically or medically – does not improve infertility. The data of this paper indicate that the conflicting findings in the literature can be explained by the fact that inactive endometriosis does not cause infertility. On the other hand active disease reduces fertility and medical or surgical therapy will lead to earlier achievement of pregnancy and higher pregnancy rates.     

子宫肌瘤剔除术中的无瘤防御

随着医学技术的进步和女性对于生殖健康认知水平的提升，越来越多的子宫肌瘤患者要求保留子宫器官，子宫肌瘤剔除术备受青睐。由于腹腔镜技术的广泛应用，以及术者对无瘤原则的忽视，近年来频频发生微创术后寄生性子宫肌瘤，甚至子宫肉瘤盆腹腔的广泛播散种植，严重危害女性生命健康，已成为重大公共卫生问题。美国食品药品监督管理局（FDA）也对腹腔镜下子宫肌瘤分碎提出黑框安全警告。建立微创无瘤防御体系势在必行，应传承并恪守无瘤原则，强调以医学教育为基础，医院管理为保障，科技创新为引领，针对子宫肌瘤剔除术中医源性肿瘤转移的多种原因，构建全方位、多层次的安全防控屏障，注重于细节管理，采取相应措施，防御肿瘤的暴露、组织碎屑的产生、体液血液的污染，保障患者的安全。     

The ethics of gene therapy and abortion: public opinion

On the grounds that the public should be consulted in decisions concerning the legitimate scope of germ-line genetic therapy (GLGT), survey data on the ethics of GLGT were collected from a large (n = 1,403) representative national sample of Australians in 2002. The data show that opinion is quite divided over GLGT in the case of a 'death sentence' genetic defect: 36% would forbid it, 23% have mixed feelings and 41% would allow it. For less serious conditions there is more opposition to GLGT. Thus, 48% would forbid GLGT to remedy a minor physical defect and 52% would oppose GLGT to counteract a propensity to violence, but fully 73% would disallow GLGT for cosmetic reasons. The data also show that opposition to abortion is lower than opposition to GLGT in the case of a 'death sentence' genetic defect, but at about the same level as, or greater than, opposition to GLGT for less serious issues. The questions show good measurement properties, including low missing data rates, so they are likely to provide an accurate picture of the public's views on the ethics of GLGT. It is suggested that a system for monitoring public opinion on these issues be developed.     

End-of-life decisions in neonates

In a large percentage of the infants who die in the neonatal intensive care setting, an end-of-life decision was made before death, usually a decision to forego life-sustaining treatment. This was confirmed in a recent study in The Netherlands that showed also that a minority of cases include the administration of drugs to hasten death, usually in patients with severe congenital multiple or central nervous system anomalies. Over 80% of Dutch pediatricians support this option under certain conditions. Almost all pediatricians are of the opinion that these cases have to be subject to public review, but they favor review by a committee of independent medical, judicial, and ethical professionals rather than by the public prosecutor. A discussion group on this subject recently made a proposal for such a reviewing procedure to the Dutch governmental authorities and described the requirements concerning end-of-life decisions in neonatal medicine. Proper handling of ethical aspects of medical treatment including review and feedback after end-of-life decisions can contribute to high standards of quality of care.     

Ethical dimensions of human immunodeficiency virus infection during pregnancy

Physicians encounter complex and sensitive ethical challenges in the medical care of pregnant women with human immunodeficiency virus (HIV) infection. This paper identifies those ethical challenges and provides concrete clinical guidance for how they should be addressed in obstetric care. The paper begins with a brief historical review, to highlight and to call into question the civil rights model of the ethics of HIV infection that has dominated the literature, clinical practice, and public policy. The authors propose an alternative ethical framework. This framework begins by underscoring the public health obligations of both physicians and pregnant women with HIV infection. The framework is based on a clinical ethics that appeals to both beneficence-based and autonomy-based obligations of the physician to the pregnant woman and the beneficence-based obligations of both the physician and the pregnant woman to the fetal patient. This framework is then deployed in a clinical ethical analysis of termination of pregnancy and contraception, partner notification, disclosure and confidentiality of her serostatus by the patient to the health care team, disclosure and confidentiality of her serostatus to other health care professionals, prevention of vertical transmission, and advance directives.     

Die Geburtsklinik als Zugpferd für das Krankenhaus der Zukunft

If maternity clinics nowadays show an unusual slump in birth rate, go into the red or are threatened with closure, it is rarely due to medical deficits but rather to deficits in the professional, scientifically based dealing with the patient groups and inadequate competitive strategies. Maternity clinics are a recession area in the health system with predatory competition. However, the thoughtless sacrifice of a maternity clinic would be fatal for the whole hospital, because there is no better showpiece health department and no other department is more suited as image bearer. For flat-rate remuneration the predatory competitive society will run in the future under the motto“be better than the others but without producing more costs than the others”. This means a change in strategy from the old logic of success with resources of burdensome“performance ethics” to a new strategy of success with resources of protective“abstention ethics” where mothers and their babies should always be the winners in the achievement competition. All results originate from the as yet most comprehensive German benchmarking initiative based on satisfaction research (300 or 100 maternity clinics).     

General Practitioners in Public Obstetrics - an Underutilized Resource

Summary: We questioned 229 general practitioners (GPs), 288 women who had recently delivered babies in public hospitals, 26 public hospital doctors, and 33 midwives in South Brisbane. Shared antenatal care was undertaken by 84% of mothers, and recently provided by 88% GPs. Mothers valued having sufficient time with their antenatal clinician, continuity of care, and short waiting and travel times. They preferred a GP to provide antenatal care, and a hospital midwife to deliver them. GPs were interested in providing even more obstetric care - one third in providing intrapartum care - and in gaining continuing education in obstetrics. Hospital doctors and midwives were supportive of women choosing the personnel to deliver them, and of an increased GP and midwife role in public hospital obstetrics, but unenthusiastic about home deliveries. There is widespread support for an increased role for GPs in public obstetrics.     

Blood flow and oxygen delivery to fetal organs as functions of fetal hematocrit

The purpose of our experiments was to relate blood flow and oxygen delivery (blood flow x arterial blood oxygen concentration) to fetal organs as functions of fetal hematocrit. In 12 chronically catheterized fetal lambs, we observed two patterns of responses of fetal organs and tissues to isovolemic alterations in fetal hematocrit from 12% to 55%. In group 1 organs (brain, heart, adrenal glands), blood flows increased as hematocrit was either raised or lowered from normal such that oxygen delivery to these organs was stable over the entire range of hematocrits studied. In group 2 organs (gastrointestinal tract organs, spleen, kidneys, placenta, and carcass), blood flows varied little over the range of hematocrits from 12% to 40% or 45% but decreased at hematocrits greater than or equal to 40% to 45%. Because of these flow responses, oxygen delivery to these organs and tissues was maximal at hematocrits ranging from 32% to 38%. Our data indicate that the various organs of the unanesthetized fetal lamb respond in different ways to alterations in hematocrit. It is of particular interest that, in the great majority of the organs of the fetus, oxygen delivery is maximal at hematocrits considered normal for the fetal lamb in utero.     

Post-partum urogenital and perineal prolapse

BACKGROUND: It is well known that vaginal birth, even under apparently normal circumstances, involves a significant mechanical straining of the various muscular connective structures which make up the pelvic floor and that an unusual strain of the perineal plates can cause morphologic-functional alterations which are not entirely reversible. The integrity of structures which make up the "pelvic floor" and the "endopelvic fascia" is the fundamental element to maintaining a normal anatomic position of the pelvic organs in the various functional conditions. Consequently prolapse of female pelvic organs can be linked back to the functional limitations of perineal plates (muscular support fascia system) and/or of the ligaments of the sub-peritoneal endopelvic connective tissue (ligament suspension system). METHODS: After birth 537 mothers underwent a urological and gynecological examinations as follows: collection of clinical data regarding pregnancy development and birth; medical history regarding the number of day- and night-time urinations, urinary volume, possible encouraging factors and pre-urinary sensations; objective urological and gynecological examination (pubo-coccygeal test, highlighting of possible agonistic and antagonistic muscular synergies, stress test, evaluation and staging of vaginal prolapse according to Baden and Walker; instrumental evaluation in cases of post-partum urinary incontinence. Simple regression analyses were carried out where prolapse of various vaginal segments were proportionately related to the various risk factors. RESULTS: Maternal age at birth, parity, weight before pregnancy and at term, weight increase, duration of second stage of labour, development and characteristics of the birth, perineal condition and neonatal weight were all variables considered risk factors while prolapse in each vaginal segment, PC-test, involuntary reflex execution of opposite command and uterine retroversion were all "response variables" whose dependence on various risk factors was studied. Analysis of the associations between the various pairs of variables showed a correlation, both positive and negative, whether the population considered was that of all mothers or that of primiparae. CONCLUSIONS: In the light of the results of this study, it can be said that there are two important pathogenetic factors: the tissue factors and the iatrogenic factor. Elevated maternal age and multiparity underline the role of the tissue factor in the pathogenesis of obstetric perineal damage. With regard to the iatrogenic factor it is interesting to note a higher concentration of symptomatic women cases where labour had been induced or birth had been achieved through instrumental delivery.     

An alternative cost effectiveness analysis of ThinPrep in the Australian setting

OBJECTIVE: To assess the clinical and economic impacts of the use of liquid based cytology (LBC) in the Australian average risk population from the perspective of the public health care budget. BACKGROUND: Concerns over the evaluation of medical technologies in Australia, which are assessed by the Medicare Services Advisory Committee (MSAC), have been raised recently. We report on the evaluation of LBC, which although being widely adopted in other parts of the world, has, despite substantial uptake in the private sector in Australia, been rejected for public funding by MSAC. METHODS: We used the health economic model developed by MSAC, but populated the model with the best available international data, sourced from a published review article. The economic model considered the clinical benefits and the costs arising from a biennial cervical screening programme. Net costs divided by life years saved is the cost per life year saved and this is reported as the incremental cost effectiveness. RESULTS: Populating the MSAC model with data on test performance showed that one type of LBC (ThinPrep) 'dominates' the conventional Pap smear in the screening of average risk women in the Australian setting. CONCLUSION: The health economic model created by MSAC predicts that ThinPrep dominates the conventional Pap as a screening test for cervical cancer. An additional 2240 high-grade lesions could be detected, resulting in 480 life years gained and delivering an expected saving to the health care system of $5,536,000 per annum if liquid based cytology replaced the conventional Pap.