Physicians' ethical responsibilities in addressing racial and ethnic healthcare disparities

Patients belonging to racial and ethnic minority populations continue to receive lesser-quality healthcare relative to other patients, even when controlling for relevant demographic variables. Such disparities represent a significant challenge for physicians who are ethically committed to serving all patients equally, irrespective of personal characteristics. Accordingly, this report explores the ethical obligations of individual physicians and the medical profession as they pertain to racial and ethnic disparities in healthcare. To address these disparities, the AMA Council on Ethical and Judicial Affairs recommends that physicians customize the provision of medial care to meet the needs and preferences of individual patients. Moreover, physicians must learn to recognize racial and ethnic healthcare disparities and critically examine their own practices to ensure that inappropriate considerations do not affect clinical judgment. Physicians can also work to eliminate racial and ethnic healthcare disparities by encouraging diversity within the profession, continuing to investigate healthcare disparities, and supporting the development of appropriate quality measures.     

Legal and ethical aspects of the vegetative state

The diagnosis of persistent or permanent vegetative state (PVS) raises ethical and legal problems. Strict adherence to the doctrine of the sanctity of life would require carers to continue to maintain the individual, perhaps for many years. However, few would regard this as an appropriate outcome when the person clearly has no capacity to interact with the environment and has no likelihood of recovery. However, the ethical and legal commitment to the sanctity of life has led courts to employ a variety of approaches to this situation in order to find a way in which the person in PVS can be allowed to die. It is argued that each of the approaches is disingenuous and ultimately unhelpful. What the law is doing is endorsing non-voluntary euthanasia, but dressing it up as something else. This is unhelpful for all concerned and the time has come for a review of all end of life decisions so that doctors, patients, and relatives can make honest decisions without fear of legal reprisal.     

Epidemiological and ethical aspects of multiplex autoantibody testing

Arrays are one of the technologies able to detect autoantibodies by measuring simultaneously many thousands of markers from a unique biological sample. The main purpose of a diagnostic test is making an early and accurate diagnosis. From a statistical point of view, multiple testing increases the probability of false positive and false negative results. Some correction methods are available to account for this problem for instance family-wise error rate or false discovery rate. From an ethical point of view, the decision to accept or decline a test not requested has to be made autonomously. Some people may seek clarification about tests and implications of their choices. A scarcity of proven measures to reduce mortality has to be considered too. Reasons may also include avoidance of psychological harm or anxiety. Moreover, protection of confidentiality and privacy has to be respected. In conclusion, the fact that testing is optional and that surveillance advice can be offered on the basis of risk alone without a test should be discussed in the consultation. The implication of a positive test result should be discussed to make a decision about the degree to which early treatment of the condition is better than late (or no) treatment.     

Assisted reproduction practice in Europe: legal and ethical aspects

This report describes the ethical and legal aspects of assistedreproductive technologies (ART) that have been instituted inEuropean countries. The data were collected from questionnairescirculated to fertility centres in 39 countries in Europe. Ninetysix ART centres were located in 30 of these countries. Ninecountries do not offer ART services. According to the survey,there are approximately 516 centres in Europe, which representapproximately 60% of the world ART centres. The survey includedinformation regarding regulation of ART services, access tothese services, attitude toward genetic material donation, cryopreservationof pre-embryos, surrogacy, manipulation of gametes and pre-embryos,research on pre-embryos and multiple fetal pregnancy reduction.At present, the majority of countries in Europe do not haveestablished legislation pertaining to the various aspects ofART practice. The study reviews the ethical and legal aspectsof ART practice in Europe.     

Lysosomal storage diseases: natural history and ethical and economic aspects

Potential treatment for lysosomal diseases now includes enzyme replacement therapy, substrate reduction therapy, and chaperone therapy. The first two of these have been implemented commercially, and the spectrum of diseases that are now treatable has expanded from Gaucher disease to include several other disorders. Treatment of these diseases is extremely costly. We explore some of the reasons for the high cost and discuss how, by proper selection of patients and appropriate dosing, the economic burden on society of treating these disease may be ameliorated, at least in part. However, the cost of treating rare diseases is a growing problem that society needs to address.     

Wegener's granulomatosis--a disease of many faces

We describe a case of Wegener's granulomatosis. The first symptoms included severe headache subsiding only after administration of dexamethasone. Despite a great number of diagnostic tests involving CT and MR of the head, the cause of the headache remained unknown. Because a chest x-ray revealed a nodule in the right lung, the patient was sent to our Clinic. Reevaluation of CT and MR pointed to a massive ethmoid sinusitis. 7-days' course of antibiotics and corticosteroids induced remission of the lung nodule. Several diagnoses were made: neoplasm, bacterial ethmoid sinusitis, trigeminal neuritis, thrombotic cavernous sinusitis and tuberculosis. Results of the ethmoid sinus biopsy together with a high c-ANCA concentration gave the correct diagnosis.     

Cord blood banking: ethical and cost–benefit aspects

Cord blood represents a new source of stem cells on the edge of fetal and postnatal life. Increasing interest in stem cell therapy has moulded cord blood banking scope, evolving to a multidisciplinary platform exceeding the classic field of haemotherapy. This review intends to re‐analyse this and presents the new aspects of cord blood banking that direct it to a model of cell pharmacy in a globalized world.     

The pathology of endometriosis: a survey of the many faces of a common disease emphasizing diagnostic pitfalls and unusual and newly appreciated aspects

Although the histologic diagnosis of endometriosis is usually straightforward, many diagnostic problems can arise as a result of alterations or absence of its glandular or stromal components. The diagnostic difficulty in such cases can be compounded by tissue that is limited to a small biopsy specimen. The appearance of the glandular component can be altered by hormonal and metaplastic changes, as well as cytologic atypia and hyperplasia. Although the last 2 findings are often referred to collectively as "atypical endometriosis," they should be separately recognized as their premalignant potential likely differs. In some cases, the endometriotic glands are sparse or even absent (stromal endometriosis). The stromal component can be obscured or effaced by infiltrates of foamy and pigmented histiocytes, fibrosis, elastosis, smooth muscle metaplasia, myxoid change, and decidual change. Occasional findings in endometriosis that may raise concern for a neoplasm include necrotic pseudoxanthomatous nodules, polypoid growth (polypoid endometriosis), bulky disease, and venous, lymphatic, or perineural invasion. Inflammatory and reactive changes within, adjacent to, or at a distance from foci of endometriosis can complicate the histologic findings and include infection within endometriotic cysts, pseudoxanthomatous salpingitis, florid mesothelial hyperplasia, peritoneal inclusion cysts, and Liesegang rings. The histologic diagnosis of endometriosis can also be challenging when it involves an unusual or unexpected site. Five such site-specific problematic areas considered are endometriosis on or near the ovarian surface, superficial cervical endometriosis, vaginal endometriosis, tubal endometriosis, and intestinal endometriosis, including the important distinction of an endometrioid carcinoma arising from colonic endometriosis from a primary colonic adenocarcinoma. Finally, endometriotic foci can occasionally be intimately admixed with another process, such as peritoneal leiomyomatosis or gliomatosis, resulting in a potentially confusing histologic appearance.     

Some ethical and psychiatric aspects of right-lobe liver transplantation in the United States and Japan

Cadaver sources are insufficient for the increasing demand for liver transplantation. Right-lobe liver transplantation from living donors is fully developed in Japan and has been rapidly increasing in the United States during the past 2 years, although donor risk is greater than in other types of solid organ transplantation. The authors examine the psychiatric and ethical aspects of right-lobe liver transplantation in light of cultural differences between the United States and Japan.     

Regulatory, financial and ethical aspects of routine clinical magnetic resonance spectroscopy

After years of technological development, magnetic resonance spectroscopy (MRS) is now being used with increasing frequency as a routine diagnostic tool for medical evaluation of patients. The transition of MRS from the realm of pure research to that of routine clinical application has been accompanied by some confusion regarding regulatory, financial and ethical matters. This contribution summarizes these issues from the author's perspective and calls for increased discussion and learning within the MRS community regarding practical matters associated with routine clinical implementation of MRS.     

Practical guidelines addressing ethical issues pertaining to the curation of human locus‐specific variation databases (LSDBs)

More than 1,000 Web‐based locus‐specific variation databases (LSDBs) are listed on the Website of the Human Genetic Variation Society (HGVS). These individual efforts, which often relate phenotype to genotype, are a valuable source of information for clinicians, patients, and their families, as well as for basic research. The initiators of the Human Variome Project recently recognized that having access to some of the immense resources of unpublished information already present in diagnostic laboratories would provide critical data to help manage genetic disorders. However, there are significant ethical issues involved in sharing these data worldwide. An international working group presents second‐generation guidelines addressing ethical issues relating to the curation of human LSDBs that provide information via a Web‐based interface. It is intended that these should help current and future curators and may also inform the future decisions of ethics committees and legislators. These guidelines have been reviewed by the Ethics Committee of the Human Genome Organization (HUGO). Hum Mutat 31:–6, 2010. © 2010 Wiley‐Liss, Inc.     

Iatrogenic disease: the clinical and social aspects

Iatrogenic disease is considered as an unintentional or occasionally inevitable damage to the patient which is caused by the medical personnel during the patient management or at examinations, diagnostic and therapeutic procedures. Iatrogenesis, being the reverse side of medicine, is an essential part of medical progress. Any therapeutic exposures, especially to invasive techniques, are prone to both positive and negative effects. The development of the physician's skill, cultural standard, refinement, continuing self-education and analysis of errors in line with governmental program to improve public health are to warrant iatrogenic disease control.     

Genetic aspects of Alzheimer disease

Alzheimer disease is the most common cause of dementia and represents a major public health problem. The neuropathologic findings of amyloid-β plaques and tau containing neurofibrillary tangles represent important molecular clues to the underlying pathogenesis. Genetic factors are well recognized, but complicated. Three rare forms of autosomal-dominant early-onset familial Alzheimer disease have been identified and are associated with mutations in amyloid precursor protein, presenilin 1, and presenilin 2 genes. The more common late-onset form of Alzheimer disease is assumed to be polygenic/multifactorial. However, thus far the only clearly identified genetic risk factor for Alzheimer disease is Apo lipoprotein E. The ε4 allele of Apo lipoprotein E influences age at onset of Alzheimer disease, but is neither necessary nor sufficient for the disease. The search continues for the discovery of additional genetic influences.