Evaluation of the effect of a patient decision aid about vasectomy on the decision-making process: a randomized trial

BackgroundBetween 7% and 10% of men who choose vasectomy as a contraceptive method regret their decision. This study evaluates the effect of a patient decision aid (PtDA) designed to help men decide whether or not to have a vasectomy.Study DesignMen considering vasectomy were randomized to an experimental group that received a full PtDA containing information and values guidance (n=32) or to a control group that received an abridged PtDA containing information only (n=31).ResultsMean Decisional Conflict Scale (DCS) scores before and after the intervention were 2.6±0.4 and 1.9±0.4 in the experimental group and 2.5±0.4 and 1.8±0.4 in the control group (p=.94), respectively. Mean knowledge of vasectomy scores before and after the intervention were 50%±16% and 72%±18% in the experimental group and 55%±18% and 71%±15% in the control group (p=.40), respectively. At baseline, all participants were undecided as to whether to have a vasectomy. After the intervention, 60% of experimental group participants and 53% of control group participants had made a definite decision (p=.58).ConclusionIn men considering vasectomy, both versions of the PtDAs improved the quality of decision-making process to a similar extent. Information alone may be sufficient to support good decision making in these patients.     

An organizational ethics decision-making process

The management team of Memorial Medical Center must make a decision regarding the continuation of one of its outpatient clinics. To provide better community service, MMC developed three outpatient clinics throughout a large metropolitan area. Over the past several years, one of the clinics has consistently been a financial loser. The losses have grown even as the costs of maintaining the clinic have increased. A primary reason for the negative financial performance is the high amount of nonreimbursed healthcare services-the clinic provides needed healthcare to a low-income part of the metropolitan area. Several members of the executive management team believe MMC has no alternative other than closing the clinic. One member of the management team, however, believes that the situation raises ethical concerns, and that executive seeks an ethics-grounded response to the problem.     

The decision-making process of health care utilization in Mexico

Using individual-level data from the 2000 Mexican Survey of Satisfaction with Health Services we estimate a two-part negative binomial hurdle model to evaluate the decision-making process of health care utilization in Mexico. We find that there are income-related differences in utilization associated with the first visit to a physician, as well as substantial utilization differences by region, employment, insurance and financial status. There are also income-related differences in the first visit to a specialist but not in the number of days hospitalized. The results suggest that increasing initial access to services via income and insurance coverage and providing financial resources to underserved regions can substantially improve access to care and, ultimately, population health.     

The decision-making process: implications for the medical school organization

In this article, the authors make use of some contemporary models of decision-making to show how the process of decision-making can become more self-conscious, and thus both more enlightened and more assured. The approach is an examination of several models examined both from the perspective of the steps in the process itself, as well as general observations about the decision-making process. The practical focus is on the medical school organization with its unique characteristics. This article also examines the decision-making process through a comparison of two types of organizational structure (pyramidal and matrix) found in most medical schools. Certain constants emerge from this article that positively enhance good decision-making. These elements are: (1) the rapidity of change; (2) the critical need for a wide range of alternatives; (3) an understanding of both the organizational structure and human factors involved; and (4) the necessity of involving others in the decision-making process. By analyzing various modes of decision-making and presenting options, this article should be of real assistance to administrators.     

The decision-making process for requests for late termination of pregnancy in Israel

This article outlines and reflects on the current procedure in Israel for requesting late pregnancy terminations and the subsequent decision-making processes. The study population consisted of 183 women who requested late termination of pregnancy (LTP) in Israel during the years 1995-97. The main causes for requests were fetal anomalies and late application. Eighty-two percent of requests were approved, and approval could be predicted by the week of gestation and the reason for application. Ethical dilemmas are described. The need to enhance professional support for women who request LTP, whether they receive approval or not, should be addressed by the health system and social workers in health care.     

Simply modified no-scalpel vasectomy (percutaneous vasectomy)--a comparative study against the standard no-scalpel vasectomy

BACKGROUND AND PURPOSE: The simply modified no-scalpel vasectomy (SMNSV; percutaneous vasectomy) technique was reported to simplify the standard no-scalpel vasectomy (SNSV) procedure. In this report, we introduce our experiences with SMNSV in comparison with the SNSV. MATERIALS AND METHODS: Between July 1999 and June 2002, 417 men were prospectively randomized to be vasectomized at the Taipei Medical University Hospital: 215 acceptors underwent the SNSV and the remaining 202 received the SMNSV. Using the no-scalpel vasectomy instruments in a percutaneous fashion, the sharp no-scalpel hemostat punctures the skin directly instead of fixating the vas to the skin with the use of a ring clamp, as done in SNSV. The vas is then grasped with the ringed instrument instead of piercing the vas and performing the supination maneuver, as described for SNSV. The intraoperative conditions of each group were recorded. The postoperative pain and life conditions were self-reported. The pain level was assessed using a 10-cm visual analogue scale under various situations. RESULTS: The time required for the SMNSV technique was less than that for the SNSV technique (p < .05). There were no significant differences between the two groups with respect to incision length, postoperative pain, pain at coitus, time of return to work, time of resuming intercourse, self-reported satisfaction in sexual life, postoperative psychological status, postoperative body weight change and postoperative complications (p > .05 for all items). CONCLUSIONS: The simply modified vasectomy technique simplifies the SNSV technique. It combines the minimally invasive nature of SNSV with the simplicity of classical vasectomy while conserving many comparable advantages.     

The option for vasectomy and gender relations

A qualitative study was performed to: investigate the process that leads couples to decide for vasectomy; characterize the gender relations involved in this process; and identify sources of information on vasectomy. Semi-structured interviews were conducted with 20 couples who had requested vasectomy at the outpatient clinic of the Center for Integrated Women's Health Care, State University in Campinas, S?o Paulo, Brazil. A structured form was used to collect social, economic, and demographic data. The content analysis technique was used for data analysis. The majority of couples opted for vasectomy as a last resort after attempting numerous other contraceptive methods, not always successfully. The emerging gender relations showed fluctuation between: (1) a more rigid, quasi-patriarchal model characterized by male predominance in the family's decision-making and (2) a more ambiguous model in relation to reproductive decisions, whereby women assumed responsibility for contraception until the situation became untenable, at which point men faced up to the unavoidable necessity of sterilization. At this point the male partners felt they should collaborate.     

The admission process in nursing homes: a clinical model for ethical decision-making

With increases in the number of older persons in our society, especially in the ranks of the oldest-old, practitioners in long-term-care settings will be faced with greater numbers and more complex issues in the nursing home admission process. This article discusses and includes case examples of some of the major problems involved in nursing home admission. Furthermore, the article proposes a clinical model which helps practitioners identify and organize information about admissions to select an appropriate course of action.     

Counselling for vasectomy

In the United Kingdom the provision of vasectomy service differs according to the geographical locations within the country. Regarding the interview that occurs prior to the vasectomy operation, 3 areas of concern must be covered: information regarding the nature of the operation and its effects must be conveyed to the client; the doctor must feel confident that he/she can recommend the couple to the surgeon performing the operation; and helping the couple to explore personel feelings and experiences about birth control and providing information on all possible choices. Although the latter aspect -- counseling -- is probably the most important, it is usually the least explored. The reason for this is inherent to the procedure through which a vasectomy is currently obtained. The couple regard the interview as a situation where the doctor will either allow or refuse the operation. Conflicts may arise if the family planning doctor simultaneously tries to play both medical and counseling roles. Further confusion arises between the screening and counseling aspects of the prevasectomy interview. Vasectomy clinics have less rigid criteria than individual surgeons. A step that must be taken if vasectomy counseling is to be improved is to increase general awareness and acknowledgment of the combined goals of the preoperative interview.     

Attitudes to vasectomy

4 surveys were conducted in the United Kingdom in an attempt to determine the personal and social factors influencing the decision to have a vasectomy. The surveys differed from other vasectomy studies in that they represented couples requesting a vasectomy and not only those who obtained a vasectomy. They include, therefore, individuals who were refused and those who changed their minds, as well as those individuals on whom the operation was performed. The surveys showed that by 1978 the majority of requests came from couples who had 2 children or less (70%), who came from social class 3 (64%), and where the wife was under age 35. There was a relative absence of high-parity couples, of the least skilled, and of those of African or Asian origin. The husbands viewed vasectomy as a final act of male contraceptive responsibility. The reasons for choosing vasectomy were to prevent further pregnancies and to protect the wife from the health risks of the oral contraceptive or the IUD and from the dangers of childbearing or the fear of pregnancy. The findings of the first 3 surveys were similar. All surveys suggested that men of low parity preferred vasectomy and that men of high parity and those of African or Asian origin were often reluctant to undergo a vasectomy. All the marriages described as successful remained so after vasectomy. Minor degrees of impotence, frigidity or lack of libido appeared to improve. 11% of the couples withdrew from the operation following the counseling session. The 476 couples requesting vasectomy in the first 3 surveys produced a wide range of anxieties over health, life problems, sexual enjoyment, contraception, children, marriage, and the change of life. There appeared to be marked differences between couples who undergo vasectomy and those choosing tubal ligation.     

Ethical analysis of the decision-making process in occupational health practice

BACKGROUND: Changes in workplaces and work organizations represent a challenge for governments, social partners and occupational health professionals whose aim is to appropriately satisfy emerging requirements and needs. An increasing number of occupational health problems requires a high-quality standard practice supported by ethically consistent decisions. The ethical aspect of the practice is strictly linked to that of appropriateness, involving requirements of effectiveness, efficiency and respect of ethical principles of the individual, community and society. OBJECTIVES AND METHODS: The paper aims at focusing the ethical components of the quality of an occupational health program by taking a systematic approach to the ethical problems. The approach consists of a 2-step process. The first step consists of appraising the basic ethical principles of the dilemma ("to do good": to prevent or to remove evil and to do or to promote good; "not to do evil", implying not to inflict evil; to do no harm; autonomy implying respect of other's freedom and self-determination; justice implying equity, solidarity and non discrimination). The second step consists of detecting the stakeholders involved or interested in the decision. The alternatives are discussed according to the assessment of ethical costs (violating the consistentprinciple) and ethical benefits (fulfilment of the consistent principle) for the stakeholders. RESULTS: Systematic analysis of the ethical components of the dilemma according to ethical principles and their discussion within a framework involving different stakeholders makes it possible to recognise ethical costs and ethical benefits of the alternative decisions. The decisions may have different costs and benefits, which should be considered and weighed to take a proper decision. Although there is no certainty about the suitability of the decision, the assessment of the ethical components may be a valuable tool in decision-making based on the awareness that any ethical aspect has been considered. CONCLUSION: Occupational health professionals are requested to act with respect for general ethical principles and preferences of the individual, groups and setting. A high-quality practice will take into account the ethical content and the ethical conduct and any intervention will include analysis of ethical principles to compare alternative decisions and their consequences for the different stakeholders. This approach guarantees a practice based on, in addition to scientific evidence, the assessment of ethical costs and ethical benefits to favour decisions preventing conflicts.