The Pediatrician's Moral Obligation to Counsel Directively Against Youth Tackle Football

In this issue of The Journal of Clinical Ethics, Professor Ruth Tallman argues that pediatricians ought to support adolescent football players in their athletic goals. She does not deny that doing so means "helping children hurt themselves"; rather she argues that this would be consistent with a shared decision-making model in which both the physician and the patient seek to promote the patient's well-being in light of the patient's own goals. I argue that this ignores the role of the parents, meaning that Tallman is suggesting "helping parents allow their children to hurt themselves." As a general pediatrician, I would classify this as child neglect, if not downright child abuse. I argue that pediatricians should counsel directively against youth tackle football, employ a deliberative approach to shared decision making within the triadic doctor-patient-parent relationship, and support youth sport policies that seek to reduce traumatic brain injury by advocating for flag football, by prohibiting checking in boys' ice hockey, and by minimizing heading the ball in soccer below a certain age.

Counseling Women on Long Acting Reversible Contraceptive (LARC) Use While Maintaining Reproductive Justice

[Full article available at http://rimed.org/rimedicaljournal-2017-10.asp].

'Hey everybody, don't get pregnant': Zika, WHO and an ethical framework for advising

WHO recently issued new guidance on the prevention of sexual transmission of Zika virus. The updated guidance states that '[c]ountry health programmes should ensure that… [i]n order to prevent adverse pregnancy and fetal outcomes, men and women of reproductive age, living in areas where local transmission of Zika virus is known to occur, be correctly informed and oriented to consider delaying pregnancy'. While the media has reported this advice as WHO telling couples in Zika-affected regions to avoid pregnancy, WHO states that they are not doing that. In an interview with the New York Times, a spokesperson from WHO stated, 'it's important to understand that this is not WHO saying, "Hey everybody, don't get pregnant." It's that they should be advised about this, so they themselves can make the final decision'. In this statement, the WHO's spokesperson distinguishes between actively directing individuals to delay pregnancy and advising them, which is portrayed as a merely informative act that facilitates but does not direct an individual's final decision. This paper proposes that advising should not be understood as a purely informational and non-directive act. The choices that agencies make in what advice to offer and to whom to offer the advice are ethical choices with practical implications. We will thus lay out a framework for considering the ethical issues that arise in the context of advising and demonstrate how it can be used to evaluate the WHO guidance.

A case report of embryo donation: ethical and clinical implications for psychologists

Third-party reproduction is a growing field, and an increasing body of literature considers the ethics of embryo donation. Due to the psychosocial complexities that generally accompany the donation and/or use of donor embryos, psychologists can play a pivotal role in these specialised fertility cases. While laws in the USA are in place to regulate the medical procedures involved in embryo donation, only unenforceable guidelines exist for psychologists specialising in fertility cases. The presentation of this case study aims to: (1) clarify the ethical concerns that fertility psychologists should consider in similar situations by assessing whether American Society of Reproductive Medicine (ASRM) and the American Psychological Association (APA) guidelines compete or complement one another within this case of embryo donation and (2) consider the interests, obligations and rights of all parties involved. Several principles, standards and guidelines that must be considered are described. Overall, the APA Ethics Code and the ASRM Guidelines appear to complement one another for most aspects of this case. Fertility psychologists should consider the clinical implications of the interests, rights and duties of all involved parties, including themselves.

Lifestyle, health and the ethics of good living. Health behaviour counselling in general practice

OBJECTIVE

To present theory that illustrates the relevance of ethics for lifestyle counselling in patient-centred general practice, and to illustrate the theory by a qualitative study exploring how doctors may obstruct or enhance the possibilities for ethical dialogue.

METHODS

The theoretical part is based on theory of common morality and Habermas' communication theory. The empirical study consists of 12 consultations concerning lifestyle changes, followed by interviews of doctors and patients.

ANALYSIS

Identification of two contrasting consultations holding much and little ethical dialogue, "translation" into speech acts, and interpretation of speech acts and interviews guided by theory.

RESULTS

General advice obstructed possibilities for ethical clarification and patient-centredness. Ethical clarification was asked for, and was enhanced by the doctor using communication techniques such as interpretation, summarization, and exploration of the objective, subjective and social dimensions of the patients' lifeworlds. However, to produce concrete good decisions an additional reflection over possibilities and obstacles in the patient's lifeworld is necessary.

CONCLUSION

Consultations concerning lifestyle changes hold opportunities for ethical clarification and reflection which may create decisions rooted in the patient's everyday life.

PRACTICE IMPLICATIONS

The study suggests that GPs should encourage active reflection and deliberation on values and norms in consultations concerning lifestyle changes.

ACOG Committee Opinion No. 363: patient testing: ethical issues in selection and counseling

Recommendations to patients about testing should be based on current medical knowledge, a concern for the patient's best interests, and mutual consultation. In addition to establishing a diagnosis, testing provides opportunities to educate, inform, and advise. The ethical principles of respect for autonomy (patient choice) and beneficence (concern for the patient's best interests) should guide the testing, counseling, and reporting process. Clear and ample communication fosters trust, facilitates access to services, and improves the quality of medical care.

Cancer genetics and its "different faces of autonomy"

In this article we discuss the development of a practice of screening, preventive treatment, and presymptomatic testing for individuals at risk of Familial Adenomatous Polyposis (FAP), a specific hereditary predisposition for colon cancer. We describe this development as a process of co-evolution, showing how this practice has been gradually taking shape in a new network of actors, routines, rules, institutions and technologies. We further argue that, looking at the emergence and transformation of this practice, we can distinguish two different regimes: a regime of prevention and a regime of self-determination. In each of these regimes the autonomy of patients and individuals at risk is shaped in a different way, that is, through a different complex of ideals, procedures, institutions, technologies, and routines. In our view, the interference between these two regimes is an important characteristic of the emergent new genetics and is reflected in the growing debate about non-directivity in genetic counselling. However, as our argument implies, when facing the challenges of the new genetics we should not restrict the debate to the quality and ethics of counselling, but extend our view to the whole complex of elements and activities which shapes individual autonomy in the context of different regimes.

To know or not to know? Genetic ignorance, autonomy and paternalism

This paper examines some arguments which deny the existence of an individual right to remain ignorant about genetic information relating to oneself--often referred to as 'a right to genetic ignorance' or, more generically, as 'a right not to know'. Such arguments fall broadly into two categories: 1) those which accept that individuals have a right to remain ignorant in self-regarding matters, but deny that this right can be extended to genetic ignorance, since such ignorance may be harmful to others, particularly those to whom one is genetically related (the 'harm to others objection') and 2) those which contend that, even if genetic ignorance is only self harming, it is not something to which individuals can rationally or morally claim to have a 'right' at all, since they defend their claims on autonomy-respecting grounds and ignorance is inimical to autonomy (the 'incoherence objection'). I argue that defenders of a right not to know have some plausible responses to the 'harm to others objection', they and their opponents reach an impasse in which both sides are left voicing concerns about the paternalistic implications of the other's point of view. I conclude that defenders of a right not to know would, therefore, advance their position further by analysing it in terms of values other than those of autonomy and rights.

Relational ethics and genetic counseling

Genetic counseling is viewed as a therapeutic interrelationship between genetic counselors and their clients. In a previous relational ethics research project, various themes were identified as key components of relational ethics practice grounded in everyday health situations. In this article the relational ethics approach is further explored in the context of genetic counseling to enhance our understanding of how the counselor-client relationship is contextually developed and maintained. Qualitative interviews were conducted with six adult clients undergoing genetic counseling for predictive testing. Engagement, dialogue and presence were revealed as relevant to genetic counselor-client relationships. A relational ethics approach in genetic counseling challenges the concept of nondirectiveness and may enhance the outcome of counseling for both counselor and client.

[Prognosis for the fetus with congenital heart defects in the era of modern diagnostics and therapeutics]

BACKGROUND

Prenatal detection of structural heart diseases and rhythm disturbance has become possible using echocardiography. Authors have already documented the high diagnostic accuracy of intrauterin diagnosis of heart diseases in our country as well.

AIM OF THIS STUDY

To examine the prognosis of fetal cardiac diseases diagnosed by echocardiography in the institute between 1985-2001.

METHODS

The prognosis of 223 (6.3%) cardiac anomalies found in 3468 fetal echocardiograms was assessed by postnatal echo/surgery/or autopsy.

RESULTS

The authors detected cardiac anomalies in 153, rhythm disturbance in 70 fetuses. They could follow (mean 4.2 yrs) the 83% of patients by postnatal echo/surgery or autopsy. They lost 46 pts (36%) by elective termination, intrauterine death, or during the postnatal period. 83% of these pts had hypoplastic left heart syndrome, fibroeleastosis, or aortic stenosis. Right heart anomalies (tetralogy of Fallot, critical pulmonary stenosis etc.) showed good prognosis with early surgical or catheter intervention. Isolated fetal supraventricular tachycardias can be successfully treated prenatally, and fetal complete heart block by emergency postnatal permanent pacemaker implantation.

CONCLUSIONS

Fetal echocardiography must be considered in our country also such a method which can influence the natural history of fetal heart diseases. The result of infant cardiac surgery also dramatically improved, so we think this knowledge is very important during the counselling.

Psychosocial genetic counseling in the post-nondirective era: a point of view

For three decades nondirectiveness has served as the central ethos for genetic counseling. It has evolved from narrow definitions defining what should not be done to broad definitions that promote active counseling skills in support of client autonomy and informed decision making. As broad definitions have been formulated, the term "nondirective" has become largely irrelevant to their content; it persists primarily as a historic relic. It has thus become an impediment to creative theory and clinical practice. I propose that nondirectiveness be replaced as the central ethos, while relevant components (providing balanced information, not imposing the counselor's values) are retained as elements of practice and ethics. This raises the question of what principle(s) should be adopted as a new guiding ethos. To promote a discussion of that issue I propose that the central ethos of genetic counseling should be to bring the psychosocial component into every aspect of the work.

Genetic testing and primary care: a new ethic for a new setting

For several decades, clinical geneticists have espoused two key ethical principles, nondirectiveness and confidentiality. These principles made a great deal of sense in the highly personal and controversial setting of reproductive genetics. Now that clinical genetics has entered the primary care setting, clinicians are rethinking the strength of their commitment to these traditional norms and they are revamping their ethical priorities. Patients increasingly need advice about whether they should take genetic tests and whether and how they should respond to the test results. Patients also need to know about how this information will impact family members and whether other members of their family should be tested. Clinical geneticists may even consider breaking individual confidentiality in order to prevent harms to family members. Although clinical geneticists do not need to abandon nondirectiveness and confidentiality in this new setting, they may not strictly adhere to these principles in some circumstances in order to benefit patients and their families.

Genetic counseling and the disabled: feminism examines the stance of those who stand at the gate

This essay examines the possible systematic bias against the disabled in the structure and practice of genetic counseling. Finding that the profession's "nondirective" imperative remains problematic, the authors recommend that methodology developed by feminist standpoint epistemology be used to incorporate the perspective of disabled individuals in genetic counselors' education and practice, thereby reforming society's view of the disabled and preventing possible negative effects of genetic counseling on the self-concept and material circumstance of disabled individuals.

Antenatal screening and its possible meaning from unborn baby's perspective

In recent decades antenatal screening has become one of the most routine procedure of pregnancy-follow up and the subject of hot debate in bioethics circles. In this paper the rationale behind doing antenatal screening and the actual and potential problems that it may cause will be discussed. The paper will examine the issue from the point of view of parents, health care professionals and, most importantly, the child-to-be. It will show how unthoughtfully antenatal screening is performed and how pregnancy is treated almost as a disease just since the emergence of antenatal screening. Genetic screening and ethical problems caused by the procedure will also be addressed and I will suggest that screening is more to do with the interests of others rather than those of the child-to be.

Genetic counselling: ethical mediation of eugenic futures?

This paper examines some proposals concerning the involvement of genetic counsellors in reproductive decisionmaking. This involvement represents the future situation as being shaped decisively by the "relevant" knowledge of powerful medical and other political interests. The paper deconstructs and reorders this proposed knowledge in order to make it problematic. The projected involvement of genetic counselling backed by claims of ethical expertise is rendered denaturalised and particular, opening a conceptual space for the emergence of other futures. An alternative future in which public communication, not private medical decisions, is given as the primary ethical focus.

Moral issues arising from genetics

Gene therapy, pre-natal diagnosis, genetically altered bacteria, patenting new life forms: these are all outgrowths from the development of genetics. Our focus will be on the moral issues engendered by some of the genetic techniques which are now so well integrated into clinical medicine. The section on genetic counseling is meant to show the most frequent moral problems encountered as they might really occur. Genetic screening is presented as a mix of preventive medicine and aid for genetic counseling. Genetic engineering is discussed in the context of evolution and human needs and desires.