Medical,legal and ethical considerations concerning the choice of bloodless medicine by Jehovah's Witnesses

The management of patients who are Jehovah's Witnesses involves important medical, legal, and ethical considerations. A court case in Japan upheld 'the patient's right to decision-making' as part of the patient's 'personal right.' When the patient is a mature minor, his or her wishes should also be respected. Even when the patient is a young child, all appropriate and available alternatives should be exhausted before considering a blood transfusion. Transfusion-alternative strategies have made it easier to choose bloodless medicine and surgery. This matter of treating the 'whole person' should be considered with all its related factors in mind.     

Practical aspects of the issue of patients refusing medical care

The issue of patients refusing medical care is one of the most difficult and complicated in the medicolegal world, and involves moral and philosophical questions in addition to medical and legal ones. Article 13 (A) of the Israeli Patient Rights Law of 1996 (hereinafter: "the Patient Rights Law") emphasizes the autonomy of the patient over his body and explicitly states that "No medical care will be given to a patient unless informed consent is given by him..." Article 13 (B) (4) of the Patient Rights Law states that obtaining informed consent requires the caregiver to give the patient the medical information required to a reasonable extent to allow the patient to decide whether to agree to the proposed care, including information on the odds and risks of alternate medical treatments. It is important to clarify, however, that the patient's right to give or withhold informed consent to medical care, does not grant him under any circumstances a right to dictate to the caregiver to use medical methods that are unconventional or that are not medically indicated, thus violating the known edict: primum non nocere (first, do no harm). This paper provides some case studies and discussion of illustrative situations.     

The court medical expert in France: changes in status

In France the status of the court expert has undergone a significant change with the adoption of statute no. 2004-130 of 11 February 2004 and its implementing regulations no. 2004-1463 of 23 December 2004. This article looks at the two most outstanding aspects of this change in status: (i) the conditions for registering on a court of appeal list and, (ii) the practical details of the quality control of the court expert's work as exercised by the judge. The article concludes with a brief comparison with the expert witness situation in England and Wales.     

Treating acute anaemia in a Jehovah's Witness in Israel: an innovative approach to a medical and legal challenge

A person's right to control his or her own body, expressed through the concept of informed consent to medical treatment, has gained worldwide acceptance. Nevertheless, this right may conflict with the state's interest in preserving life in cases where patients refuse treatment in medical emergencies. This paper examines the management of treating acute anaemia in a Jehovah's Witness in Israel who refused blood transfusion on religious grounds. The medical and legal ramifications are discussed in light of the Israeli Patients' Rights Law of 1996. This law established statutory ethics committees which may, under defined conditions of emergency or threat to life, approve treatment against the patient's will. This power, previously vested in the courts, should be used only in extreme circumstances while, in general, patients' wishes and beliefs must be respected. Sensitivity to the legal and ethical aspects involved deserves greater emphasis in medical school curricula.     

Population exposure to ionizing radiation from medical examinations in France

This study was carried out to update data concerning both the nature and the frequency of X-ray diagnostic procedures and to reassess the associated per caput effective dose in France, given that the only nationwide survey was carried out over 15 years ago. Relevant data concerning examinations in conventional radiology, computed tomography, interventional radiology and nuclear medicine were obtained for the year 2002 from two main sources: the main health insurance records for private practices and the statistics of healthcare establishments on hospital activity. Doses associated with different types of examination were obtained from the diagnostic reference levels (DRL) campaign, together with data from the European Commission and from the Health Protection Agency in the UK. The results show that between 55.4 and 65.9 million procedures were performed in 2002 in conventional radiology (one-third for dental) and between 4.2 and 6 million in computed tomography. There were 850,000 and 900,000 procedures in nuclear medicine and interventional radiology respectively. Conventional radiology accounts for 90% of the total number of procedures but only 37% of the collective dose, whereas examinations in computed tomography account for 8% of total examinations but 39% of the collective dose. Examinations in nuclear medicine and interventional radiology account for 2% of procedures but 7% and 17% of the collective dose respectively. Finally, the per caput effective dose in 2002 was between 0.66 and 0.83 mSv.     

Medical attention seeking dance injuries: systematic review of case reports

The objective of this study was to conduct a systematic review of case reports documenting the epidemiology of unique and rare musculoskeletal injuries in dancers. A systematic review was conducted online using PubMed and Google Scholar, as per PRISMA guidelines up to July 30, 2016. Predefined eligibility criteria were applied, and the data thus compiled was analysed. Study quality was assessed based on CARE guidelines. 72 studies reporting 92 dance injuries were included in the review. The average age of dancers was 23 years (SD = 10 years) with majority being females (65%). Chronic injuries were the most common presentation with lower extremity injuries being the commonest. Foot and knee injuries were the top two articulations involved across injuries and groups. Overall bony injuries were most frequently reported, with stress injury being the most common type. Conservative approach was the most commonly reported treatment approach across case reports. The methodological quality of case reports included in the study varied considerably and lacked uniformity. The evidence provided, though not sufficient for any recommendation, it should alert the physicians and those concerned with the primary care of the dancers to be vigilant of the eccentricity and severity of the injuries, their atypical presentation, mode, mechanism and trend, thereby being prepared for the unexpected.     

重视面授教学存在的问题提高医学函授教育质量

函授是继续教育中一种较普遍的形式，在继续教育中占有比较重要的位置。函授教育的优越性主要在于：人才培养量大，培养范围广，少受地域限制；培养专业设置较丰富，学习的选择余地大，针对性强；特有的教学方式使得工学能兼顾，尤其适宜不能离岗的在职人员学习。应该肯定，函授教育为改善干部的知识结构，提高干部学历层次和综合素质，促进部队建设和发展作出了成绩。但是，我们也必须看到，函授教育在人才培养的质量上还存在着不少问题，人才的“含金量”不够高，其质量问题也影响到了函授教育的进一步发展。     

Application of the case method in medical student radiology education

RATIONALE AND OBJECTIVES: Our goal is to design, implement, and evaluate a rich educational activity to engage medical students in learning the importance of providing clinical histories when ordering radiological examinations. We adapted the format of the case method commonly used in business schools. MATERIALS AND METHODS: In the setting of a 1-week required radiology course offered during the third year of medical school, we created an unknown case assignment consisting of two chest radiographs and a concise history for three- to four-person study teams. Unknown to students, each team received the same images, but different patient histories. After turning in their written analyses, students had a classroom opportunity to discuss their conclusions. A written evaluation of the entire experience using both Likert items and unstructured response items was conducted at the end of each session. RESULTS: The evaluation was conducted during a 17-month period, and 141 evaluations were received from students. The response rate was 100%. Most teams met several times and worked on the assignment for 2 or 3 hours. Students agreed that the learning experience was worthwhile (95%), content was appropriate (93%), and the activity should be continued for subsequent classes (94%). Unstructured responses indicated that students learned the importance of clinical histories in the interpretation of radiological studies. CONCLUSION: An educational activity based on the case method was well received by students and met its educational objectives. Activities of this type have potential for widespread application in radiology education.     

MRI in France: the French paradox

Although France is a modern, developed country, which spends nearly 10% of the gross national product on healthcare and has a highly praised level of medicine, the number of modern imaging scanners, such as CT (595), MRI (182), and PET (5), is quite low when compared to other European countries. Politics and a long-standing tradition of centralization are prominent among reasons for such an underdevelopment. This situation has resulted in another French paradox not linked to wine consumption. The French life expectancy is very high, but the number of imaging equipment is very low.     

The Jehovah's Witnesses' refusal for blood transfusions: the jurisprudence and the medico-legal debate in Italy

The Jehovah's Witnesses (JWs) patient's refusal of a lifesaving transfusion creates a conflict for the physician. In Italy, we are met with a great disparity of behaviour among physicians; the JW's eventual refusal for transfusional therapy often necessitates the physician's recourse to the court. Jurisprudence has thus arrived at an analysis of the juridical value of so-called advance directives. The analysis demonstrates a noteworthy argumentative coherence and reflects a specific doctrinaire development in transfusional therapy. In fact, in Italy most of medicolegal doctrine recognizes, in the JW's blood refusal, the physician's limited position whereby, it seems, he or she must submit legally to an expressed therapeutical dissent even when the patient is in a condition of incompetence and is no longer capable of expressing his or her refusal, or else must risk an indiscriminate violation of the patient's right to religious freedom and choice. According to the Constitutional Chart, the physician's duty to respect the JW's refusal of blood transfusions is absolute in order to avoid any treatment that is in conflict with the religious faith that each patient is free to profess.     

Department of Defense medical transformation: a case for the Defense Health Agency

What are the threats facing the military health system (MHS) in the first quarter of the 21st century? The Department of Defense has decided that the emerging threats of weapons of mass destruction, information and asymmetrical warfare, well-organized terrorist groups, and rogue nations are going to require a transformation in future force structure and operational concepts. Is the MHS continuing to train and equip itself for the battlefield casualties of the Korean and Vietnam conflicts, or is it truly prepared for the emerging threats of the 21st century? Reliance on gradual, incremental change will not be sufficient to combat new emerging threats to the United States. Transformation is a radical concept; it demands a wholesale review of how the MHS views and accomplishes the mission. It does not accept the comfort afforded by slow, gradual evolution in military doctrine and organizational structure that bureaucracy affords. The Department of Defense is transforming. The MHS also needs to embrace transformational restructuring; to train and equip for the war on the horizon, to keep pace with the warfighter, and to provide integration and interoperability with other federal, state, and local agencies in support of homeland defense. More than two dozen formal audits, boards, studies, and reviews have questioned the necessity, efficiency, and effectiveness of the three services medical departments; yet the MHS has undergone little transformational change since World War II. The transformational model that will best support the operational forces and the United States in the coming decades is the Defense Health Agency model.     

A case in south-eastern France: a review of drug facilitated sexual assault in European and English-speaking countries

Drug facilitated sexual assaults (DFSA) have been increasingly reported in the medical literature since the 1980s but their legal recognition is more recent, at least in Europe. From a case treated in south-eastern France, whose judicial consequences were known, it seemed of interest to carry out an international study of jurisprudence concerning this type of rape. While from the medical viewpoint the drugs used are well-known and their presence can be clinically verified, the legal consequences of their use in subsequent criminal prosecution is less clear-cut. Some European countries have no jurisprudence in this area, while others consider the use of drugs as an aggravating circumstance. In France, it was only in 2003 that the first case of DFSA was truly punished by the judicial system, with considerable media attention. By contrast, in English-speaking countries, particularly the United States, the use of drugs to facilitate sexual assault has frequently been recognized in legislation and in criminal prosecutions. Prevention is fundamental and is recognised as demonstrated by campaigns in various countries.     

Validity of the SMS,Phone, and medical staff Examination sports injury surveillance system for time‐loss and medical attention injuries in sports

The accurate measurement of sport exposure time and injury occurrence is key to effective injury prevention and management. Current measures are limited by their inability to identify all types of sport‐related injury, narrow scope of injury information, or lack the perspective of the injured athlete. The aims of the study were to evaluate the proportion of injuries and the agreement between sport exposures reported by the SMS messaging and follow‐up telephone part of the SMS , Phone, and medical staff Examination (SPE x) sports injury surveillance system when compared to measures obtained by trained on‐field observers and medical staff (comparison method). We followed 24 elite adolescent handball players over 12 consecutive weeks. Eighty‐six injury registrations were obtained by the SPE x and comparison methods. Of them, 35 injury registrations (41%) were captured by SPE x only, 10 injury registrations (12%) by the comparison method only, and 41 injury registrations (48%) by both methods. Weekly exposure time differences (95% limits of agreement) between SPE x and the comparison method ranged from −4.2 to 6.3 hours (training) and −1.5 to 1.0 hours (match) with systematic differences being 1.1 hours (95% CI 0.7 to 1.4) and −0.2 (95% CI −0.3 to −0.2), respectively. These results support the ability of the SPE x system to measure training and match exposures and injury occurrence among young athletes. High weekly response proportions (mean 83%) indicate that SMS messaging can be used for player measures of injury consequences beyond time‐loss from sport. However, this needs to be further evaluated in large‐scale studies.     

The medical management of acute appendicitis in a nonsurgical environment: a retrospective case review

The treatment of acute appendicitis in remote environments without the capability of surgical intervention appears to be effective when using antibiotic protocols active against both aerobic and anaerobic bacteria. A review of nine such cases treated with various antibiotic protocols was conducted and demonstrated good response in all patients. This aggressive medical management frequently resulted in complete resolution of symptoms in patients who later required elective appendectomy or who had recurrences, with similar symptoms requiring acute appendectomies. A strong index of suspicion for appendicitis must be maintained in these cases and one must rely on the medical documentation of the initial episode and proceed with a thorough surgical evaluation.