Medical oath: use and relevance of the Declaration of Geneva. A survey of member organizations of the World Medical Association (WMA)

The Declaration of Geneva is one of the core documents of medical ethics. A revision process was started by the World Medical Association (WMA) in 2016. The WMA has also used this occasion to examine how the Declaration of Geneva is used in countries throughout the world by conducting a survey of all WMA constituent members. The findings are highly important and raise urgent questions for the World Medical Association and its National Medical Associations (NMA): The Declaration of Geneva is only rarely used as an oath text despite the fact that physicians’ oaths are generally widespread. This is not consistent with the intention and claim of the Declaration of Geneva. The article then discusses three questions. Should there be one single binding oath? Which organization should be responsible for such an oath? Which oath is the most obvious candidate? In a globalized world and despite all cultural diversity, the medical profession should have one core moral basis which is binding for physicians all over the world. The most obvious candidate for an oath incorporating this moral basis is the Declaration of Geneva.     

The new medical oath in The Netherlands

The Hippocratic oath derives its name from the ancient Greek physician Hippocrates. It has been embraced as a code of conduct by the medical profession throughout the ages, and is used by medical faculties as an explicit moment of reflection during graduation ceremonies. Although this oath is primarily of ceremonial value, it was felt that the text needed revision as it no longer reflected the current ethical norms in the Netherlands. The new Dutch oath drawn up in 2003 has a dual function: it is symbolic in that it represents the end of a doctor's training, but it is also intended to trigger the discussion of moral issues during the medical studies.     

城镇医保对口腔医疗卫生服务费用影响因素的探讨

目的通过对城镇医保及非医保居民在口腔医疗卫生服务费用的定量研究,探讨其影响因素,为当前城镇医疗保险制度及口腔医疗费用支付提供科学依据。方法利用2008-2010年在湖南省人民医院口腔科就诊患者的连续性资料按照享有医保及非医保患者分为两类,采用单因素分析比较两者口腔医疗服务费用及多元回归分析法对口腔卫生服务费用影响因素进行分析。结果医保患者在次均口腔医疗费用及年总口腔医疗卫生服务费用均比非医保患者高;是否46-64岁、是否大于65岁、是否科技干部、是否商业服务、是否离退休、文化程度、收入、储蓄、是否拔牙、是否急性牙痛是医保及非医保患者的口腔医疗服务费用的影响因素,其中是否离退休、是否46~64岁、文化程度、是否急性牙痛、患者收入是医保患者口腔医疗卫生服务影响最显著的5个因素;而是否拔牙、是否急性牙痛、是否离退休、文化程度、患者收入是非医保患者口腔医疗卫生服务费用影响最显著的5个因素。结论医保患者的口腔医疗卫生服务费用要高于非医保患者,且费用主要影响因素也不同。本研究结果可为长沙市口腔医疗保障制度及口腔医疗卫生服务费用预测提供一定的参考依据。     

Ethical Issues in the Economic Assessment of Health Care Technologies

This paper challenges traditional views which oppose health economics and medical ethics by arguing that economic assessment is a necessary complement to medical ethics and can help to improve public participation and democratic processes in choices about resource allocation for health care technologies. In support of this argument, four points are emphasized: (1) Most current biomedical ethical debates implicitly deal with economic issues of resource allocation. (2) Clinical decisions, which usually respect the Hippocratic code of ethics, are nevertheless influenced by economic incentives and constraints. (3) Economic assessment is concerned with both efficiency and equity and potential trade-offs between the two, which means that ethical judgements are always embedded in welfare economics. (4) The real debate is not between economics on the one side and medical ethics on the other. Rather it is between different ethical conceptions of social justice and the contrasting approaches they entail to reconciling individual interests and preferences with collective goods and welfare. This revised version was published online in August 2006 with corrections to the Cover Date.     

Screening for postpartum depression with the Edinburgh Postnatal Depression Scale (EPDS): an ethical analysis

AIMS: To assess the Edinburgh Postnatal Depression Scale (EPDS), a self-administered questionnaire created to screen for symptoms of postpartum depression in the community, from an epidemiological and ethical perspective. Screening, as the practice of investigating apparently healthy individuals to detect unrecognised disease or its precursors, has interpretation problems and is complicated by deliberations on probabilities for something to occur, on which the scientific community is unanimous. METHODS: Our ethical analysis is made using a framework with two different dimensions, the ethical principles autonomy and beneficence and the affected persons. To balance the ethical costs and the ethical benefits of EPDS an analogy with the assessment of pharmaceutics is used. RESULTS: In this article we argue that routine EPDS screening of Swedish postpartum women would lead to considerable ethical problems due to the weak scientific foundation of the screening instrument. Despite a multitude of published studies, the side-effects in terms of misclassifications have not been considered carefully. The EPDS does not function very well as a routine screening instrument. The dualism created is too reductive and fails to recognize the plurality of difference that exists in the social word. CONCLUSIONS: Public health authorities should not advocate screening of unproved value. Screening is not just a medical issue but also an ethical one.     

谁是科技论文的作者?

随着科学发展,特别是那些为科学研究付出代价的人们的影响与日俱增,产生了一些道德和编辑方面的问题。谁对科技论文中发表的成果的质量和可靠性负责?更主要的是,谁是这样一篇论文的作者?在诺丁汉(英国)的一次会议上讨论了这些问题。     

Ethical, logical and scientific problems with the new ICRP proposals.

Last year the ICRP proposed a new system of radiation protection designed to be simpler, more oriented toward individual protection and reflective of important ethical standards. This article argues that the proposal violates important norms of scientific simplicity, is in fact less protective of individuals than the current system and makes a number of ethical errors. After outlining 12 ethical errors, five logical errors and two scientific problems with the new ICRP proposal, the present authors suggest possible ways to remedy these deficiencies.     

Shades of blue: the negotiation of limited codes by medical residents.

One of the most difficult decisions facing physicians in contemporary medical practice is whether to initiate or withhold cardiopulmonary resuscitation (CPR) for patients who are critically ill. Because of the problems surrounding these decisions, hospital guidelines have recently been developed for the appropriate use of do-not-resuscitate (DNR) orders. Despite the establishment of these guidelines, problems with the application of DNR orders remain. This study examines one strategy used by internal medicine resident physicians to cope with the problematic nature of decisions regarding resuscitation--the use of partial or slow resuscitation attempts, known as 'limited codes.' It analyzes how these code efforts play a role within the context of resident work by enabling residents to circumvent ethical and practical dilemmas created by the circumstances of their clinical practice.     

The ethical dilemmas of human life: the hospital history of children with serious cerebral palsy

This study deals with the ethical premises of medical treatment for children with serious cerebral palsy. Eight months of ethnographic research were carried out with patients at the Cerebral Palsy Center in the Sarah Hospital in Salvador, Bahia, Brazil. Observation of treatment for these children, who displayed limited clinical change, led to the following question, as suggested by discussions from medical deontology: What is the purpose of medical treatment for children with serious cerebral palsy? The results of our research point to social and humanist explanations going beyond the official medical scientific explanation, which limits treatment to corporal mechanicism.     

Physicians for ten years: a longitudinal survey of the career development of physicians who began their studies in Groningen,the Netherlands

OBJECTIVE: To analyse the career development of two cohorts of medical graduates from the University of Groningen, the Netherlands. DESIGN: Structured interviews. METHOD: For all 333 graduates who commenced undergraduate medical training in 1982 and 1983, data were collected for the period 1993-2000 with respect to resident training, income, job load, job satisfaction and scientific research. Gender differences were analysed for all of the variables. This was done by means of structured interviews as well as a strategic search in Medline and the on-line public catalogue of the University of Groningen. RESULTS: In the year 2000, 73% of the graduates had enrolled in resident training, 8% had not succeeded in finding a place. The wish to work part-time had increased strongly over the years. In general, job satisfaction was reasonable. In total 31% of the cohort had published one or more English articles or written a thesis. Gender differences were found for job load and publications. CONCLUSIONS: Ten years after graduation, medical careers had become established. Men had not succeeded in fulfilling their wishes to work part-time. Women were disadvantaged with respect to their scientific career.     

留学期限与后效益分析

目的：了解出国人员留学期限与个人及社会效益之间的关系。方法：采用对某医院有留学经历的科技人员发放问卷调查的方法。结果：在留学一年、半年和两年3组人员中,分别有89．7％、90．5％和91．3％的人认为,留学对他们观念的更新有很大或较大影响;93．1％留学一年、95．7％留学两年人员认为,外语水平有很大或较大的提高;留学一年的社会效益指标普遍高于留学半年,而留学二年的社会效益指标与留学一年组相比无明显差异;93．2％人员认为,最合适、最经济的出国留学期限为一年。结论：出国留学一年是获得个人和社会效益较为适宜的选择。     

Moral imperialism and multi-centric clinical trials in peripheral countries

Moral imperialism is expressed in attempts to impose moral standards from one particular culture, geopolitical region or culture onto other cultures, regions or countries. Examples of Direct Moral Imperialism can be seen in various recurrent events involving multi-centric clinical trials promoted by developed (central) countries in poor and developing (peripheral) countries, particularly projects related to the theory of double standards in research. After the WMA General Assembly refused to change the Helsinki Declaration - which would have given moral recognition to the above mentioned theory - the USA abandoned the declaration and began to promote regional seminars in peripheral countries with the aim of "training" researchers on ethical perspectives that reflect America's best interests. Individuals who received such training became transmitters of these central countries' ideas across the peripheral countries, representing a form of Indirect Moral Imperialism. The paper proposes the establishment of regulatory and social control systems for clinical trials implemented in peripheral countries, through the formulation of ethical norms that reflect the specific contexts of these countries, along with the drawing up and validation of their own national norms.     

1995-2004年福建省医药卫生科技论文计量分析

目的了解福建省医药卫生科研实力和学术水平,为科研管理提供量化参考。方法对CBMDisc收录的1995-2004年福建省医药卫生科技论文进行统计分析。结果总发文量57726篇,呈逐年增长趋势。第1作者人数为19545人,人均发表论文2.95篇,论文合著率74.73%,作者合作度2.81。基金资助论文占6.86%,基金论文的比重逐年提高。附有引文的论文占57.01%,平均引文率为3.35篇。结论福建省医药卫生科技水平正逐年提高,但地区发展不均衡,福州高等院校和三级医院科研实力和科研水平较为突出,在医药卫生科技发展方面起主导作用;科研骨干群正逐步形成,但科技人员的合作意识和情报意识尚须加强。     

Impact of a national medical fee schedule revision on the cessation of physician home visits among older patients in Tokyo: A retrospective study

As Japan's population continues to age rapidly, the national government has implemented several measures to improve the efficiency of healthcare services and to control rising medical expenses for older patients. One such measure was the revision of the medical fee schedule for physician home visits in April 2014, in which eligibility for these visits was restricted to patients who are unable to visit outpatient clinics without assistance. Through an investigation of patients who were receiving physician home visits in Tokyo, this study examines whether this fee schedule revision resulted in an increase in patients who transitioned from home visits to outpatient care. In a retrospective analysis of health insurance claims data, we examined 80,914 Tokyo residents aged 75 years or older who had received at least one physician home visit between January and May 2014. The study period was divided into four periods (January–February, February–March, March–April, and April–May), and we examined the number of patients receiving home visits in the index month of each period who subsequently transitioned to outpatient care in the following month. Potential factors associated with this transition to outpatient care were examined using a generalised estimating equation. The March–April period that included the fee schedule revision was significantly associated with a higher number of patients who transitioned from home visits in the index month to outpatient care in the following month (odds ratio: 4.46, p < 0.001) than the other periods. In addition, patients receiving home visits at residential facilities were more likely to transition to outpatient care (odds ratio: 10.40, p < 0.001). These findings indicate that the fee schedule revision resulted in an increase in patients who ceased physician home visits and began visiting outpatient clinics for treatment.     

The reluctant imperialism of the medical profession

Medical authority is invoked ever more frequently, also in situations that are outside the scope of scientific medicine. The main but latent function of this medicalization is the resolution of social conflict. This occurs more often than not in tacit collusion between a work organization (or the wider community) on the one hand, the individualized 'patient' on the other hand and the doctor as the arbiter who defines socially contested issues in terms of medical problems. As scientific medicine provides insufficient justification of these medical interventions, they threaten to become the subject of open controversy within the organized medical profession and thus to undermine professional unanimity, and with it the authority of the profession as a whole. This explains the reluctance of organized medicine to claim these new fields as its legitimate province.     

2013年-2017年全国三级公立医院神经重症医疗质量现状分析

目的了解我国三级公立医院神经重症住院患者医疗质量现状。方法采用病案首页主要诊断和其他诊断的疾病编码，提取医院质量监测系统中2013年1月1日-2017年12月31日诊断为神经系统疾病的神经重症患者信息。采用SPSS 21.0统计软件对相关指标数据进行分析。结果全国506家三级公立医院共计220 027例神经重症患者纳入研究，其中，男性患者居多，占住院总人次的58.61%，年龄中位数（四分位数）为58（27，72）岁。患者住院死亡率和平均住院天数呈逐年下降趋势，出院人数逐年增加，机械通气时间逐年缩短，31天重返ICU率在小范围内波动。神经重症患者付费方式以城镇职工基本医疗保险为主，新型农村合作医疗保险次之。结论我国神经重症医疗质量逐年上升，救治水平在逐步提高，未来仍需继续关注结构、过程、结局指标，以持续改进。     

Lung function and symptoms among cotton workers and dropouts three years after the start of work

A longitudinal study of cotton workers was undertaken to assess the presence of work-related medical effects. A cohort of 110 subjects was examined before starting work and one year later. Measurements of pulmonary function were made before and after the work shift. Airway responsiveness was measured using a methacholine challenge test. A questionnaire was used to determine work-related symptoms. The 60 workers who remained after three years experienced an over-shift drop in FEV1 and an increase in airway responsiveness that did not increase after the first year. The data from the dropout group (n = 50) before work and after one year were compared with those for the active workers. The dropout group had a higher prevalence of symptoms of chest tightness and nasal irritation after one year of work. Atopy was not more common in this group. The results suggest that leaving work was related to symptoms of airways inflammation but not to atopy.     

Assessment of ethical decisions and values

The development and pilot testing of the Professional Decisions and Values Test (PDV) is described. The PDV is designed to assess how ethical conflicts are dealt with by medical and law students and which moral values motivate them. Data from two consecutive classes of entering medical and law students are presented and their action tendencies and ethical values are compared. The findings support the construct validity of the test. Regarding reliability, stability over time is present for action tendencies but not for values. Perhaps the ethical values of entering medical and law students do not become stable until later. Change in ethical values can be studied with the PDV for groups, not individuals, during the first year of professional education.     

Patients' rights of the deceased and related problems in Hungarian law

In the Hungarian law, non-burial interventions on cadavers are regulated only by the health law and, therefore, other scientific examinations are theoretically not allowed. Only the international ethical code of museums is used in certain cases. Numerous cultures consider this practice as the mutilation of the cadaver. Beyond this and the criminal forms of mutilation, the medical interventions (trial and training) are also appropriate to hurt the dignity of the dead. As a counterweight, the consent of the patient or his/her relatives is needed for post-mortem interventions. This study presents the Hungarian legislation in which the deceased is a 'patient', and the special enforcement of patients' rights takes place in relation to the body. The relatives have many rights concerning autopsy, and the anatomy institutes are also regulated. The presumption of opting-out is used for organ harvesting; objection is accepted only from the patient. Medical data of the deceased are strictly protected, but there are no obstacles to the interests of the relatives. Graduate and postgraduate medical education pays only little attention to these issues, and the legislation is not in line with the present expectations and possibilities, so that it would be advisable to reconsider the full spectrum of the problem.