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1.  Top 10 health care ethics challenges facing the public: views of Toronto bioethicists 
BMC Medical Ethics  2005;6:5.
Background
There are numerous ethical challenges that can impact patients and families in the health care setting. This paper reports on the results of a study conducted with a panel of clinical bioethicists in Toronto, Ontario, Canada, the purpose of which was to identify the top ethical challenges facing patients and their families in health care. A modified Delphi study was conducted with twelve clinical bioethicist members of the Clinical Ethics Group of the University of Toronto Joint Centre for Bioethics. The panel was asked the question, what do you think are the top ten ethical challenges that Canadians may face in health care? The panel was asked to rank the top ten ethical challenges throughout the Delphi process and consensus was reached after three rounds.
Discussion
The top challenge ranked by the group was disagreement between patients/families and health care professionals about treatment decisions. The second highest ranked challenge was waiting lists. The third ranked challenge was access to needed resources for the aged, chronically ill, and mentally ill.
Summary
Although many of the challenges listed by the panel have received significant public attention, there has been very little attention paid to the top ranked challenge. We propose several steps that can be taken to help address this key challenge.
doi:10.1186/1472-6939-6-5
PMCID: PMC1180442  PMID: 15978136
2.  Inclusion of Ethical Issues in Dementia Guidelines: A Thematic Text Analysis 
PLoS Medicine  2013;10(8):e1001498.
Background
Clinical practice guidelines (CPGs) aim to improve professionalism in health care. However, current CPG development manuals fail to address how to include ethical issues in a systematic and transparent manner. The objective of this study was to assess the representation of ethical issues in general CPGs on dementia care.
Methods and Findings
To identify national CPGs on dementia care, five databases of guidelines were searched and national psychiatric associations were contacted in August 2011 and in June 2013. A framework for the assessment of the identified CPGs' ethical content was developed on the basis of a prior systematic review of ethical issues in dementia care. Thematic text analysis and a 4-point rating score were employed to assess how ethical issues were addressed in the identified CPGs. Twelve national CPGs were included. Thirty-one ethical issues in dementia care were identified by the prior systematic review. The proportion of these 31 ethical issues that were explicitly addressed by each CPG ranged from 22% to 77%, with a median of 49.5%. National guidelines differed substantially with respect to (a) which ethical issues were represented, (b) whether ethical recommendations were included, (c) whether justifications or citations were provided to support recommendations, and (d) to what extent the ethical issues were explained.
Conclusions
Ethical issues were inconsistently addressed in national dementia guidelines, with some guidelines including most and some including few ethical issues. Guidelines should address ethical issues and how to deal with them to help the medical profession understand how to approach care of patients with dementia, and for patients, their relatives, and the general public, all of whom might seek information and advice in national guidelines. There is a need for further research to specify how detailed ethical issues and their respective recommendations can and should be addressed in dementia guidelines.
Please see later in the article for the Editors' Summary
Editors’ Summary
Background
In the past, doctors tended to rely on their own experience to choose the best treatment for their patients. Faced with a patient with dementia (a brain disorder that affects short-term memory and the ability tocarry out normal daily activities), for example, a doctor would use his/her own experience to help decide whether the patient should remain at home or would be better cared for in a nursing home. Similarly, the doctor might have to decide whether antipsychotic drugs might be necessary to reduce behavioral or psychological symptoms such as restlessness or shouting. However, over the past two decades, numerous evidence-based clinical practice guidelines (CPGs) have been produced by governmental bodies and medical associations that aim to improve standards of clinical competence and professionalism in health care. During the development of each guideline, experts search the medical literature for the current evidence about the diagnosis and treatment of a disease, evaluate the quality of that evidence, and then make recommendations based on the best evidence available.
Why Was This Study Done?
Currently, CPG development manuals do not address how to include ethical issues in CPGs. A health-care professional is ethical if he/she behaves in accordance with the accepted principles of right and wrong that govern the medical profession. More specifically, medical professionalism is based on a set of binding ethical principles—respect for patient autonomy, beneficence, non-malfeasance (the “do no harm” principle), and justice. In particular, CPG development manuals do not address disease-specific ethical issues (DSEIs), clinical ethical situations that are relevant to the management of a specific disease. So, for example, a DSEI that arises in dementia care is the conflict between the ethical principles of non-malfeasance and patient autonomy (freedom-to-move-at-will). Thus, healthcare professionals may have to decide to physically restrain a patient with dementia to prevent the patient doing harm to him- or herself or to someone else. Given the lack of guidance on how to address ethical issues in CPG development manuals, in this thematic text analysis, the researchers assess the representation of ethical issues in CPGs on general dementia care. Thematic text analysis uses a framework for the assessment of qualitative data (information that is word-based rather than number-based) that involves pinpointing, examining, and recording patterns (themes) among the available data.
What Did the Researchers Do and Find?
The researchers identified 12 national CPGs on dementia care by searching guideline databases and by contacting national psychiatric associations. They developed a framework for the assessment of the ethical content in these CPGs based on a previous systematic review of ethical issues in dementia care. Of the 31 DSEIs included by the researchers in their analysis, the proportion that were explicitly addressed by each CPG ranged from 22% (Switzerland) to 77% (USA); on average the CPGs explicitly addressed half of the DSEIs. Four DSEIs—adequate consideration of advanced directives in decision making, usage of GPS and other monitoring techniques, covert medication, and dealing with suicidal thinking—were not addressed in at least 11 of the CPGs. The inclusion of recommendations on how to deal with DSEIs ranged from 10% of DSEIs covered in the Swiss CPG to 71% covered in the US CPG. Overall, national guidelines differed substantially with respect to which ethical issues were included, whether ethical recommendations were included, whether justifications or citations were provided to support recommendations, and to what extent the ethical issues were clearly explained.
What Do These Findings Mean?
These findings show that national CPGs on dementia care already address clinical ethical issues but that the extent to which the spectrum of DSEIs is considered varies widely within and between CPGs. They also indicate that recommendations on how to deal with DSEIs often lack the evidence that health-care professionals use to justify their clinical decisions. The researchers suggest that this situation can and should be improved, although more research is needed to determine how ethical issues and recommendations should be addressed in dementia guidelines. A more systematic and transparent inclusion of DSEIs in CPGs for dementia (and for other conditions) would further support the concept of medical professionalism as a core element of CPGs, note the researchers, but is also important for patients and their relatives who might turn to national CPGs for information and guidance at a stressful time of life.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001498.
Wikipedia contains a page on clinical practice guidelines (note: Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
The US National Guideline Clearinghouse provides information on national guidelines, including CPGs for dementia
The Guidelines International Network promotes the systematic development and application of clinical practice guidelines
The American Medical Association provides information about medical ethics; the British Medical Association provides information on all aspects of ethics and includes an essential tool kit that introduces common ethical problems and practical ways to deal with them
The UK National Health Service Choices website provides information about dementia, including a personal story about dealing with dementia
MedlinePlus provides links to additional resources about dementia and about Alzheimers disease, a specific type of dementia (in English and Spanish)
The UK Nuffield Council on Bioethics provides the report Dementia: ethical issues and additional information on the public consultation on ethical issues in dementia care
doi:10.1371/journal.pmed.1001498
PMCID: PMC3742442  PMID: 23966839
3.  How physician executives and clinicians perceive ethical issues in Saudi Arabian hospitals. 
Journal of Medical Ethics  1999;25(1):51-56.
OBJECTIVES: To compare the perceptions of physician executives and clinicians regarding ethical issues in Saudi Arabian hospitals and the attributes that might lead to the existence of these ethical issues. DESIGN: Self-completion questionnaire administered from February to July 1997. SETTING: Different health regions in the Kingdom of Saudi Arabia. PARTICIPANTS: Random sample of 457 physicians (317 clinicians and 140 physician executives) from several hospitals in various regions across the kingdom. RESULTS: There were statistically significant differences in the perceptions of physician executives and clinicians regarding the existence of various ethical issues in their hospitals. The vast majority of physician executives did not perceive that seven of the eight issues addressed by the study were ethical concerns in their hospitals. However, the majority of the clinicians perceived that six of the same eight issues were ethical considerations in their hospitals. Statistically significant differences in the perceptions of physician executives and clinicians were observed in only three out of eight attributes that might possibly lead to the existence of ethical issues. The most significant attribute that was perceived to result in ethical issues was that of hospitals having a multinational staff. CONCLUSION: The study calls for the formulation of a code of ethics that will address specifically the physicians who work in the kingdom of Saudi Arabia. As a more immediate initiative, it is recommended that seminars and workshops be conducted to provide physicians with an opportunity to discuss the ethical dilemmas they face in their medical practice.
PMCID: PMC479169  PMID: 10070640
4.  A proposed rural healthcare ethics agenda 
Journal of Medical Ethics  2007;33(3):136-139.
The unique context of the rural setting provides special challenges to furnishing ethical healthcare to its approximately 62 million inhabitants. Although rural communities are widely diverse, most have the following common features: limited economic resources, shared values, reduced health status, limited availability of and accessibility to healthcare services, overlapping professional–patient relationships and care giver stress. These rural features shape common healthcare ethical issues, including threats to confidentiality, boundary issues, professional–patient relationship and allocation of resources. To date, there exists a limited focus on rural healthcare ethics shown by the scarcity of rural healthcare ethics literature, rural ethics committees, rural focused ethics training and research on rural ethics issues. An interdisciplinary group of rural healthcare ethicists with backgrounds in medicine, nursing and philosophy was convened to explore the need for a rural healthcare ethics agenda. At the meeting, the Coalition for Rural Health Care Ethics agreed to a definition of rural healthcare ethics and a broad‐ranging rural ethics agenda with the ultimate goal of enhancing the quality of patient care in rural America. The proposed agenda calls for increasing awareness and understanding of rural healthcare ethics through the development of evidence—informed, rural‐attuned research, scholarship and education in collaboration with rural healthcare professionals, healthcare institutions and the diverse rural population.
doi:10.1136/jme.2006.015966
PMCID: PMC2598268  PMID: 17329381
5.  HEALTH CARE SERVICES IN SAUDI ARABIA: PAST, PRESENT AND FUTURE 
Health services in Saudi Arabia have developed enormously over the last two decades, as evidenced by the availability of health facilities throughout all parts of the vast Kingdom. The Saudi Ministry of Health (MOH) provides over 60% of these services while the rest are shared among other government agencies and the private sector. A series of development plans in Saudi Arabia have established the infra-structure for the expansion of curative services all over the country. Rapid development in medical education and the training of future Saudi health manpower have also taken place. Future challenges facing the Saudi health system are to be addressed in order to achieve the ambitious goals set by the most recent health development plan. These include the optimum utilization of current health resources with competent health managerial skills, the search for alternative means of financing these services, the maintenance of a balance between curative and preventive services, the expansion of training Saudi health manpower to meet the increasing demand, and the implementation of a comprehensive primary health care program.
PMCID: PMC3439740  PMID: 23008647
Health system; health statistics; primary health care; Saudi Arabia
6.  Education and the improvement of clinical ethics services 
BMC Medical Education  2013;13:41.
The proliferation of clinical ethics in health care institutions around the world has raised the question about the qualifications of those who serve on ethics committees and ethics consultation services. This paper discusses some of weaknesses associated with the most common educational responses to this concern and proposes a complementary approach. Since the majority of those involved in clinical ethics are practicing health professionals, the question of qualification is especially challenging as the role of ethics committees and, increasingly, ethics consultation services are becoming increasingly important to the functioning of health care institutions. Since the challenging nature of health care finances often leads institutions to rely on voluntary participation of committed health professional with only token administrative or clerical support to provide the needed ethics services, significant challenges are created for attaining competence and functional effectiveness. The article suggests that a complementary approach should be adopted for sustaining and building capacity in clinical ethics. Ethics committees and consultation services should systematically adopt quality improvement techniques to effect designed changes in clinical ethics performance and to build ethical capacity within targeted clinical units and services. Demonstrating improvements in functioning can go a long way to build confidence and capacity for clinical ethics and can help in justifying the need for support. To do so, however, requires that ethics committees and consultation services first shift attention to those areas that demonstrate weak or questionable ethical performance, including the established practices of the ethics committee and consultation service, and second seek collaboration with the involved health care providers to pursue demonstrable change. Such an approach has a much better chance of improving the capacity for clinical ethics in health care institutions than relying on educational approaches alone.
doi:10.1186/1472-6920-13-41
PMCID: PMC3608248  PMID: 23517735
Clinical ethics; Ethics consultation; Ethics committees; Education; Quality improvement
7.  Ethical Challenges of Medicine and Health on the Internet: A Review 
Knowledge and capabilities, particularly of a new technology or in a new area of study, frequently develop faster than the guidelines and principles needed for practitioners to practice ethically in the new arena; this is particularly true in medicine. The blending of medicine and healthcare with e-commerce and the Internet raises many questions involving what sort of ethical conduct should be expected by practitioners and developers of the medical Internet. Some of the early pioneers in medical and healthcare Web sites pushed the ethical boundaries with questionable, even unethical, practices. Many involved with the medical Internet are now working to reestablish patient and consumer trust by establishing guidelines to determine how the fundamentals of the medical code of ethical conduct can best be adapted for the medical/healthcare Internet. Ultimately, all those involved in the creation, maintenance, and marketing of medical and healthcare Web sites should be required to adhere to a strict code of ethical conduct, one that has been fairly determined by an impartial international organization with reasonable power to regulate the code. This code could also serve as a desirable, recognizable label-of-distinction for ethical Web sites within the medical and healthcare Internet community. One challenge for those involved with the medical and healthcare Internet will be to determine what constitutes "Medical Internet Ethics" or "Healthcare Internet Ethics," since the definition of medical ethics can vary from country to country. Therefore, the emerging field of Medical/ Healthcare Internet Ethics will require careful thought and insights from an international collection of ethicists in many contributing areas. This paper is a review of the current status of the evolving field of Medical/Healthcare Internet Ethics, including proposed definitions and identification of many diverse areas that may ultimately contribute to this multidisciplinary field. The current role that medicine and health play in the growing area of Internet communication and commerce and many of the ethical challenges raised by the Internet for the medical community are explored and some possible ways to address these ethical challenges are postulated.
doi:10.2196/jmir.3.2.e23
PMCID: PMC1761893  PMID: 11720965
Internet; Ethics, Medical; Ethics, Professional; Ethics, Informatics; Physician-Patient Relation; Code of Ethics; Research Ethics; Medical Informatics Ethics
8.  The Ethical Odyssey in Testing HIV Treatment as Prevention 
Background
Obtaining the definitive data necessary to determine the safety and efficacy of using antiretroviral treatment (ART) to reduce the sexual transmission of HIV in heterosexual couples encountered an array of ethical challenges that threatened to compromise HPTN 052, the multinational clinical trial addressing this issue that has profound public health implications.
Purpose
To describe and analyze the major ethical challenges faced in HPTN 052.
Methods
The ethical issues and modifications of HPTN 052 in response to these issues were catalogued by the principal investigator, the lead coordinator, and the ethicist working on the trial. The major ethical issues that were unique to the trial were then described and analyzed, referring as appropriate to published literature and emerging guidance and policies. Ethical challenges that must be addressed in many clinical trials, such as those related to obtaining informed consent and making provisions for ancillary care, are not described.
Results
When HPTN 052 was being designed, ethical questions emerged related to the relevance of the research question itself given data from observational research and a range of beliefs about the appropriate means of preventing and treating HIV-infection and AIDS. Further, ethical challenges were faced regarding site selection since there was a scientific need to conduct the research in settings where HIV incidence was high, but alternatives to study participation should be available. As in most HIV prevention research, ethical questions surrounded the determination of the appropriate prevention package for all of those enrolled. During the course of the trial, guidance documents and policies emerged that were of direct relevance to the research questions, calling for a balancing of concerns for the research subjects and trial integrity. When the study results were made public, there was a need to ensure access to the treatment shown to be effective that in some cases differed from the guidelines used at the sites where the research was being conducted. In addition, questions were raised about whether there was an obligation to notify subjects about “unlinked’ transmissions of HIV, that is, infections acquired outside of the designated sexual partners enrolled in the study.
Limitations
The ethical issues described are limited to those discerned by the authors and not those of other stakeholders who may have identified additional issues or had a different perspective in analyzing them.
Conclusions
Understanding the ethical challenges faced in HPTN 052 promises to inform the design and conduct of future complex, long-term clinical trials aimed at addressing critical scientific and public health questions, where data and practice patterns emerge over the course of the trial.
doi:10.1177/1740774512443594
PMCID: PMC3486723  PMID: 22692805
9.  Epidemiology of Road Traffic Injuries in Qassim Region, Saudi Arabia: Consistency of Police and Health Data 
Introduction
In Saudi Arabia, road traffic accidents (RTA) are becoming a serious public health problem. Police reports are designed for legal purposes with very little information on the health consequences. Also, health system data include detailed health information, but not related or linked to the data obtained police reports. Examining the consistency of these sources is vital to build an accurate surveillance system that can track the risk factors and the health consequences, as well as establishing and evaluating prevention interventions.
Objectives
This study is intended to:
▪ Examine the consistency of health -registration data with the data gathered by the traffic police department.
▪ Elucidate the magnitude, risk factors and outcome of RTI in Qassim region of Saudi Arabia,
▪ Compare the pattern of accidents in Qassim with those at different regions of the Kingdom.
Methodology
Health care information was collected on visits of victims of road traffic accidents to emergency and outpatients’ departments of the major hospitals in Qassim region during the year 2010. The information included the patients’ demographics, and clinical characteristics. Traffic Police Department information was also collected on all accidents that occurred in the study region. A Questionnaire was also developed and pilot tested to collect data from a random sample of population attending hospital outpatient and Primary Health Care clinics. Data included previous involvement in road traffic accident, and information about any injury; fatality or disability due to these RTI.
Results
During the study period, road traffic death rate based on death registration data was almost twice as high as the rate reported by the police (P < 0.05).
There was also a significant decline of 27% according to police-reported data during the study period, as opposed to a non-significant increase of 8% according to health registration data during the same period.
Population Survey Information showed the overall age-sex-adjusted rate for non-fatal RTI was 20.7 (95% CI, 20.0 – 21.3)/100 persons/year. The rate for non-fatal RTI is higher in the 10–19 years age group (17.3%). Males had twice or more incidence rate for RTI requiring recovery period of ≤ 7 days as compared with females, however, RTI incidence for recovery period of >7 days is more than twice in females.. Also a total of 12 deaths due to RTI were reported in 5–49 years age group in the last 3 years, representing an estimated annual RTI mortality rate of 35.4/100,000 (95% CI 16.6 – 57.8). A total of 11 participants reported RTI related disability in the last 3 years representing an estimated annual RTI disability rate of 34.1/100,000 population (95% CI 11.4 – 55.7).
Reports of the Traffic Police Department showed that 18623 accidents occurred throughout the year 2010. These accidents involved 23178 persons, and resulted in the injury of 2025 people and the deaths of 369. In contrast, the health system reports showed that 4232 people had been injured and 1054 had died.
Comparison with local & Arab Rates showed that Qassim is among the highest 5 regions in the kingdom regarding the number of RTA Saudi Arabia is also having a very high level of road traffic accidents and fatalities compared to other Arab countries.
Conclusion
RTI are responsible for significant loss of life, disability and injury in Qassim population and in Saudi Arabia. The inconsistency between police-reported data and health system data strongly suggests that active efforts to audit and monitor data quality are clearly necessary.
PMCID: PMC3523781  PMID: 23267302
RTA; Epidemiology; Qassim; KSA
10.  Pharmacoeconomic Analysis in Saudi Arabia: An Overdue Agenda Item for Action 
Annals of Saudi Medicine  2011;31(4):335-341.
Pharmacoeconomics is a branch of health economics related to the most economical and efficient use of pharmaceuticals. Pharmacoeconomic research identifies, measures and compares the costs and outcomes (clinical, economic and humanistic) of pharmaceutical products and services. Pharmacoeconomic evaluation can play a significant role in the efficient allocation of resources in healthcare systems with constrained budgets. Countries are trying to control the rising costs of health care in their aging population. They are all asking the same question: Is the new drug good value for money; and if so, what is the society willing to pay for it? This article reviews the importance of, and the need for, adaptation of pharmacoeconomic analysis to the conditions in Saudi Arabia. It will shed some light on the important steps for converting the concept into practice, including the need for identifying the willing-to-pay (WTP) or the threshold cutoff, the existence of a real cost for each utility, the nonexistence of an pharmacoeconomic advisory forum, pharmaceutical budget allocation, and the impact of pharmaceutical marketing. It will also provide recommendations for easing any challenges that might jeopardize the conduct of such analysis in Saudi Arabia.
doi:10.4103/0256-4947.83201
PMCID: PMC3156506  PMID: 21808106
11.  Patients’ perception, views and satisfaction with pharmacists’ role as health care provider in community pharmacy setting at Riyadh, Saudi Arabia 
Objectives
This study will provide guiding information about the population perception, views and satisfaction with pharmacist’s performance as health care provider in the community pharmacy setting in Riyadh, Saudi Arabia.
Method
The study was conducted in Riyadh, Saudi Arabia, from July through December 2010. A total of 125 community pharmacies in Riyadh city were randomly selected according to their geographical distribution (north, south, east, and west). They represent about 10–15% of all community pharmacies in the city. The questionnaire composed of 8 items about patients’ views and satisfaction with the pharmacists’ role in the current community pharmacy practice. The questionnaire was coded, checked for accuracy and analyzed using the Statistical Package for Social Sciences (SPSS) version 17.0 for Windows (SPSS Inc., Chicago, Illinois).
Results
The response rate was almost 85% where 2000 patients were approached and 1699 of them responded to our questionnaire. The majority of respondents is young adults and adults (82.8%), male (67.5%) and married (66.9%). Seventy one percent of respondents assured that community pharmacist is available in the working while only 37.3% of respondents perceived the pharmacist as a mere vendor. About 38% assured sou moto counseling by the pharmacist, 35% reported pharmacist plays an active role in their compliances to treatments, 43% acknowledged the role of pharmacist in solving medication related problems, 34% considered the pharmacist as a health awareness provider and 44.6% felt that pharmacist is indispensable and an effective part of the health care system.
Conclusion
The image and professional performance of community pharmacist are improving in Saudi Arabia. The Saudi patients show better satisfaction, perception and appreciation of the pharmacists’ role in the health care team. However, extra efforts should be paid to improve the clinical skills of the community pharmacists. Community pharmacists need to be able to reach out to patient, assess their hesitations and promptly offer solution which was appreciated by the patients as the survey indicates. They should play a pro-active role in becoming an effective and indispensable part of health care. Furthermore, they should be able to advice, guide, direct and persuade the patient to comply correct usage of drugs. Finally, community pharmacists should equip themselves with appropriate knowledge and competencies in order to tender efficient and outstanding pharmaceutical health care.
doi:10.1016/j.jsps.2012.05.007
PMCID: PMC3745196  PMID: 23960807
Community; Pharmacist; Satisfaction; Care; Drug; Perception
12.  Ethical challenges related to elder care. High level decision-makers' experiences 
BMC Medical Ethics  2007;8:3.
Background
Few empirical studies have been found that explore ethical challenges among persons in high public positions that are responsible for elder care. The aim of this paper was to illuminate the meaning of being in ethically difficult situations related to elder care as experienced by high level decision-makers.
Methods
A phenomenological-hermeneutic method was used to analyse the eighteen interviews conducted with political and civil servant high level decision-makers at the municipality and county council level from two counties in Sweden. The participants worked at a planning and control as well as executive level and had both budget and quality of elder care responsibilities.
Results
Both ethical dilemmas and the meaning of being in ethically difficult situations related to elder care were revealed. No differences were seen between the politicians and the civil servants. The ethical dilemmas mostly concerned dealings with extensive care needs and working with a limited budget. The dilemmas were associated with a lack of good care and a lack of agreement concerning care such as vulnerable patients in inappropriate care settings, weaknesses in medical support, dissimilar focuses between the caring systems, justness in the distribution of care and deficient information. Being in ethically difficult situations was challenging. Associated with them were experiences of being exposed, having to be strategic and living with feelings such as aloneness and loneliness, uncertainty, lack of confirmation, the risk of being threatened or becoming a scapegoat and difficult decision avoidance.
Conclusion
Our paper provides further insight into the ethical dilemmas and ethical challenges met by high level decision-makers', which is important since the overall responsibility for elder care that is also ethically defensible rests with them. They have power and their decisions affect many stakeholders in elder care. Our results can be used to stimulate discussions between high level decision-makers and health care professionals concerning ways of dealing with ethical issues and the necessity of structures that facilitate dealing with them. Even if the high level decision-makers have learned to live with the ethical challenges that confronted them, it was obvious that they were not free from feelings of uncertainty, frustration and loneliness. Vulnerability was revealed regarding themselves and others. Their feelings of failure indicated that they felt something was at stake for the older adults in elder care and for themselves as well, in that there was the risk that important needs would go unmet.
doi:10.1186/1472-6939-8-3
PMCID: PMC1855928  PMID: 17419880
13.  An ethical framework for cardiac report cards: a qualitative study 
BMC Medical Ethics  2005;6:3.
Background
The recent proliferation of health care report cards, especially in cardiac care, has occurred in the absence of an ethical framework to guide in their development and implementation. An ethical framework is a consistent and comprehensive theoretical foundation in ethics, and is formed by integrating ethical theories, relevant literature, and other critical information (such as the views of stakeholders). An ethical framework in the context of cardiac care provides guidance for developing cardiac report cards (CRCs) that are relevant and legitimate to all stakeholders. The purpose of this study is to develop an ethical framework for CRCs.
Methods
Delphi technique – 13 panelists: 2 administrators, 2 cardiac nurses, 5 cardiac patients, 2 cardiologists, 1 member of the media, and 1 outcomes researcher. Panelists' views regarding the ethics of CRCs were analyzed and organized into themes.
Results
We have organized panelists' views into ten principles that emerged from the data: 1) improving quality of care, 2) informed understanding, 3) public accountability, 4) transparency, 5) equity, 6) access to information 7) quality of information, 8) multi-stakeholder collaboration, 9) legitimacy, and 10) evaluation and continuous quality improvement.
Conclusion
We have developed a framework to guide the development and dissemination of CRCs. This ethical framework can provide necessary guidance for those generating CRCs and may help them avoid a number of difficult issues associated with existing ones.
doi:10.1186/1472-6939-6-3
PMCID: PMC1084248  PMID: 15794818
14.  “Completely out-at-sea” with “two-gender medicine”: A qualitative analysis of physician-side barriers to providing healthcare for transgender patients 
Background
Members of the transgender community have identified healthcare access barriers, yet a corresponding inquiry into healthcare provider perspectives has lagged. Our aim was to examine physician perceptions of barriers to healthcare provision for transgender patients.
Methods
This was a qualitative study with physician participants from Ontario, Canada. Semi-structured interviews were used to capture a progression of ideas related to barriers faced by physicians when caring for trans patients. Qualitative data were then transcribed verbatim and analysed with an emergent grounded theory approach.
Results
A total of thirteen (13) physician participants were interviewed. Analysis revealed healthcare barriers that grouped into five themes: Accessing resources, medical knowledge deficits, ethics of transition-related medical care, diagnosing vs. pathologising trans patients, and health system determinants. A centralising theme of “not knowing where to go or who to talk to” was also identified.
Conclusions
The findings of this study show that physicians perceive barriers to the care of trans patients, and that these barriers are multifactorial. Access barriers impede physicians when referring patients to specialists or searching for reliable treatment information. Clinical management of trans patients is complicated by a lack of knowledge, and by ethical considerations regarding treatments—which can be unfamiliar or challenging to physicians. The disciplinary division of responsibilities within medicine further complicates care; few practitioners identify trans healthcare as an interest area, and there is a tendency to overemphasise trans status in mental health evaluations. Failure to recognise and accommodate trans patients within sex-segregated healthcare systems leads to deficient health policy. The findings of this study suggest potential solutions to trans healthcare barriers at the informational level—with increased awareness of clinical guidelines and by including trans health issues in medical education—and at the institutional level, with support for both trans-focused and trans-friendly primary care models.
doi:10.1186/1472-6963-12-110
PMCID: PMC3464167  PMID: 22559234
15.  Interactions between Non-Physician Clinicians and Industry: A Systematic Review 
PLoS Medicine  2013;10(11):e1001561.
In a systematic review of studies of interactions between non-physician clinicians and industry, Quinn Grundy and colleagues found that many of the issues identified for physicians' industry interactions exist for non-physician clinicians.
Please see later in the article for the Editors' Summary
Background
With increasing restrictions placed on physician–industry interactions, industry marketing may target other health professionals. Recent health policy developments confer even greater importance on the decision making of non-physician clinicians. The purpose of this systematic review is to examine the types and implications of non-physician clinician–industry interactions in clinical practice.
Methods and Findings
We searched MEDLINE and Web of Science from January 1, 1946, through June 24, 2013, according to PRISMA guidelines. Non-physician clinicians eligible for inclusion were: Registered Nurses, nurse prescribers, Physician Assistants, pharmacists, dieticians, and physical or occupational therapists; trainee samples were excluded. Fifteen studies met inclusion criteria. Data were synthesized qualitatively into eight outcome domains: nature and frequency of industry interactions; attitudes toward industry; perceived ethical acceptability of interactions; perceived marketing influence; perceived reliability of industry information; preparation for industry interactions; reactions to industry relations policy; and management of industry interactions. Non-physician clinicians reported interacting with the pharmaceutical and infant formula industries. Clinicians across disciplines met with pharmaceutical representatives regularly and relied on them for practice information. Clinicians frequently received industry “information,” attended sponsored “education,” and acted as distributors for similar materials targeted at patients. Clinicians generally regarded this as an ethical use of industry resources, and felt they could detect “promotion” while benefiting from industry “information.” Free samples were among the most approved and common ways that clinicians interacted with industry. Included studies were observational and of varying methodological rigor; thus, these findings may not be generalizable. This review is, however, the first to our knowledge to provide a descriptive analysis of this literature.
Conclusions
Non-physician clinicians' generally positive attitudes toward industry interactions, despite their recognition of issues related to bias, suggest that industry interactions are normalized in clinical practice across non-physician disciplines. Industry relations policy should address all disciplines and be implemented consistently in order to mitigate conflicts of interest and address such interactions' potential to affect patient care.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Making and selling health care goods (including drugs and devices) and services is big business. To maximize the profits they make for their shareholders, companies involved in health care build relationships with physicians by providing information on new drugs, organizing educational meetings, providing samples of their products, giving gifts, and holding sponsored events. These relationships help to keep physicians informed about new developments in health care but also create the potential for causing harm to patients and health care systems. These relationships may, for example, result in increased prescription rates of new, heavily marketed medications, which are often more expensive than their generic counterparts (similar unbranded drugs) and that are more likely to be recalled for safety reasons than long-established drugs. They may also affect the provision of health care services. Industry is providing an increasingly large proportion of routine health care services in many countries, so relationships built up with physicians have the potential to influence the commissioning of the services that are central to the treatment and well-being of patients.
Why Was This Study Done?
As a result of concerns about the tension between industry's need to make profits and the ethics underlying professional practice, restrictions are increasingly being placed on physician–industry interactions. In the US, for example, the Physician Payments Sunshine Act now requires US manufacturers of drugs, devices, and medical supplies that participate in federal health care programs to disclose all payments and gifts made to physicians and teaching hospitals. However, other health professionals, including those with authority to prescribe drugs such as pharmacists, Physician Assistants, and nurse practitioners are not covered by this legislation or by similar legislation in other settings, even though the restructuring of health care to prioritize primary care and multidisciplinary care models means that “non-physician clinicians” are becoming more numerous and more involved in decision-making and medication management. In this systematic review (a study that uses predefined criteria to identify all the research on a given topic), the researchers examine the nature and implications of the interactions between non-physician clinicians and industry.
What Did the Researchers Do and Find?
The researchers identified 15 published studies that examined interactions between non-physician clinicians (Registered Nurses, nurse prescribers, midwives, pharmacists, Physician Assistants, and dieticians) and industry (corporations that produce health care goods and services). They extracted the data from 16 publications (representing 15 different studies) and synthesized them qualitatively (combined the data and reached word-based, rather than numerical, conclusions) into eight outcome domains, including the nature and frequency of interactions, non-physician clinicians' attitudes toward industry, and the perceived ethical acceptability of interactions. In the research the authors identified, non-physician clinicians reported frequent interactions with the pharmaceutical and infant formula industries. Most non-physician clinicians met industry representatives regularly, received gifts and samples, and attended educational events or received educational materials (some of which they distributed to patients). In these studies, non-physician clinicians generally regarded these interactions positively and felt they were an ethical and appropriate use of industry resources. Only a minority of non-physician clinicians felt that marketing influenced their own practice, although a larger percentage felt that their colleagues would be influenced. A sizeable proportion of non-physician clinicians questioned the reliability of industry information, but most were confident that they could detect biased information and therefore rated this information as reliable, valuable, or useful.
What Do These Findings Mean?
These and other findings suggest that non-physician clinicians generally have positive attitudes toward industry interactions but recognize issues related to bias and conflict of interest. Because these findings are based on a small number of studies, most of which were undertaken in the US, they may not be generalizable to other countries. Moreover, they provide no quantitative assessment of the interaction between non-physician clinicians and industry and no information about whether industry interactions affect patient care outcomes. Nevertheless, these findings suggest that industry interactions are normalized (seen as standard) in clinical practice across non-physician disciplines. This normalization creates the potential for serious risks to patients and health care systems. The researchers suggest that it may be unrealistic to expect that non-physician clinicians can be taught individually how to interact with industry ethically or how to detect and avert bias, particularly given the ubiquitous nature of marketing and promotional materials. Instead, they suggest, the environment in which non-physician clinicians practice should be structured to mitigate the potentially harmful effects of interactions with industry.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001561.
This study is further discussed in a PLOS Medicine Perspective by James S. Yeh and Aaron S. Kesselheim
The American Medical Association provides guidance for physicians on interactions with pharmaceutical industry representatives, information about the Physician Payments Sunshine Act, and a toolkit for preparing Physician Payments Sunshine Act reports
The International Council of Nurses provides some guidance on industry interactions in its position statement on nurse-industry relations
The UK General Medical Council provides guidance on financial and commercial arrangements and conflicts of interest as part of its good medical practice website, which describes what is required of all registered doctors in the UK
Understanding and Responding to Pharmaceutical Promotion: A Practical Guide is a manual prepared by Health Action International and the World Health Organization that schools of medicine and pharmacy can use to train students how to recognize and respond to pharmaceutical promotion.
The Institute of Medicine's Report on Conflict of Interest in Medical Research, Education, and Practice recommends steps to identify, limit, and manage conflicts of interest
The University of California, San Francisco, Office of Continuing Medical Education offers a course called Marketing of Medicines
doi:10.1371/journal.pmed.1001561
PMCID: PMC3841103  PMID: 24302892
16.  Legal aspects with regard to integrated care: a long way to go 
Introduction
The main purpose of this abstract is to raise awareness of the unsatisfactory legal situation with regard to integrated care. The abstract focuses on two major legal issues. First, I picture the actual legal situation regarding cross-border healthcare. Secondly, I describe the duties care providers and patients may face when entering into integrated care programs.
Cross-border healthcare
Currently, we lack an European legislative framework that regulates cross-border healthcare. One reason for this fact is that Article 152 EC treaty states that “Community Action in the field of public health shall fully respect the responsibilities of the Member States for the organisation and delivery of health services and medical care” [1]. Therefore, it's up to each Member State to provide regulations with regard to cross-border healthcare services. Hence, patients need to deal with various national—often inconsistent—provisions when considering consuming cross-border healthcare. As a consequence, patients easily felt overstrained and the unclear legal situation prevents them from crossing a border to obtain healthcare. This often averts the establishment of integrated care models. As a result, patients lose the opportunity to receive more or different healthcare services and products in Member States other than the State in which they are living or are insured.
Nevertheless, it was the European Court of Justice (ECJ) with its continuous rulings in respect to cross-border healthcare that started with the harmonization process of cross-border healthcare legislation. The ECJ judges have ruled that freedom to cross EU borders for the best and quickest treatment is a right for all [2]. However, litigation before the ECJ suffers from deficiencies in this respect. In particular, the case law of the ECJ on the issue clearly shows the unsatisfactory nature of case-by-case ex post procedures for a complex and developing policy area. Further, litigation always leads to a winner and a loser, but does not foster an iterative, deliberate process in which the optimal accommodation of all affected interests is reached because the ECJ always decides on a particular case [3]. As a consequence, the European Commission has presented a proposal for a directive on the application of patient's rights in cross-border healthcare which reflects the decisions of the ECJ [4]. The aim of the proposed directive is—expressed in simplified terms—to ensure and to clarify the conditions for exercising patient's right to cross-border healthcare, and to create a framework for increasing cooperation between Member States. The proposal directive covers cross-border healthcare irrespective of how it is organised, financed or provided and whether it is private or public. The outcome of the proposed directive would be the reduction of obstacles faced when crossing the border in order to obtain healthcare. In case the proposed directive will be approved and will come into force, a major step in order to enlarge the possibilities to achieve integrated care is done. However, the Member States (e.g. Austria) take a critical stance towards the proposed directive and no one currently knows whether it will ever be approved [5].
The actor's duties with respect to integrated care programs
Entering into an integrated care program leads to legal challenges with regard to the actors. In particular, the question which duties are faced when entering into an integrated care program has not been raised yet. Therefore, patients find themselves in situations with a deficit of information and do not see the legal consequences when entering into an integrated care program. Patients often do not realise that they conclude an agreement with a health insurance company. They bind themselves for a certain period (sometimes several years) and they are contractually not allowed to rescind from the agreement. In general, integrated care programs offered from health insurance companies oblige the patient to consult the healthcare providers that are covered from the agreement. As a consequence, in case patients are not satisfied with the healthcare provider because of medical or personal reasons, no change to another healthcare provider is possible. Further, patients always enter into an implied health treatment agreement with the healthcare provider. In turn, healthcare providers do not have any certainties to be appointed from health insurance companies and, therefore, may lose essential revenues. In addition, healthcare providers are obliged to fulfil certain requirements (technical and organisational) in order to be appointed. In case they are not able anymore to continuously fulfil these requirements, health insurance companies may rescind their contracts. Having these issues in mind, one can assume that entering into an integrated care program implies various—often unseen—duties from different perspectives.
Conclusion
At a glance, the legal background of integrated care still raises a lot of unsolved problems both on a national and on a European level. As a next step, legal uncertainties should be made transparent in order to give the actors the possibility to discuss them. A consequence of this public discussion would be a cornerstone for more consumer-friendly healthcare models that would lead to better patient treatment and would enhance integrated healthcare.
PMCID: PMC2807115
cross-border healthcare; legislation; European Court of Justice; patient's rights; legal duties; integrated care program
17.  Prevalence and determinants of smoking in three regions of Saudi Arabia 
Tobacco Control  1999;8(1):53-56.
OBJECTIVES—To study the prevalence and determinants of cigarette smoking among Saudi nationals in three regions of Saudi Arabia.
PARTICIPANTS—A sample of 8310 individuals aged 15 years and above from both sexes, randomly selected from the three regions, using a stratified cluster sampling technique.
DESIGN—A cross-sectional, household, community-based survey. Using a predesigned and tested questionnaire, the participants were interviewed by primary care physicians. The interview covered personal, social, and educational characteristics of the respondents, and also included questions about their smoking status, duration of smoking, and daily cigarette consumption.
MAIN OUTCOME MEASURES—Association between current smoking and sociodemographic variables, in univariate and multivariate analysis. Degree of interaction between the different determinants of cigarette smoking.
RESULTS—The overall prevalence of current smoking was 21.1% for males and 0.9% for females. Most smokers (78%) were young to middle-aged (21-50 years old). Smoking prevalence was higher among married people, among uneducated people, and among those in certain occupations: manual workers, businessmen, army officers, and office workers.
CONCLUSIONS—Cigarette smoking is an important public health problem in Saudi Arabia. A more intense and comprehensive tobacco control effort is needed.


Keywords: smoking predictors; smoking prevalence; Saudi Arabia
PMCID: PMC1763927  PMID: 10465816
18.  OBESITY AND ASSOCIATED RISK OF CORONARY ARTERY DISEASE AMONG PATIENTS OF PRIMARY HEALTH CARE CENTERS IN ABHA, SAUDI ARABIA 
Objective:
To estimate the magnitude of obesity and its relation to the 10 year probability of developing coronary artery disease (CAD) in patients attending primary health care centers (PHCCs) in Abha, southern Saudi Arabia.
Subjects and Methods:
Saudi patients aged between 30-70 years who had attended three PHCCs in Abha city over a 6-month period (January to June 1998) and agreed to participate in the study were enrolled. All such patients had their weights and heights measured, body mass index (BMI) was calculated and they were screened for risk factors of CAD and requested to provide a fasting venous sample for lipoprotein analysis. The probability of developing coronary artery disease (PCAD) over the next ten years was calculated for each patient by means of the computer model based on Framingham heart study.2
Results:
A total of 858 subjects were studied: 46% males and 54% females. The percentage of obesity was 49% and overweight 35%; Females were dominantly obese while overweight was more prevalent in males. Of the study subjects 11.5% were hypertensive with significantly higher BMI than normotensives (P=<0.001); diabetes mellitus was represented in 29.6% with no significant difference in their BMI from nondiabetics. Smokers were 4.2% and they had a significantly lower BMI than non-smokers. Individuals with high-risk threshold of TC/HDL-c ratio (≥ 5.6% for women and ≥ 6.4% for men) represented 70.48% and had significantly higher BMI than those with low risk threshold. There was no direct relationship between BMI and PCAD10 (r2=0.007, p<0.12).
Conclusion:
(1) Obesity is an epidemic health problem with an expected upward trend in Saudi Arabia similar to that of LISA and Western Europe. (2) The risk factors for CAD were highly prevalent among the PHCC patients and had a strong significant association with obesity; thus weight control should be an integral part of the prevention of CAD at PHCCs level. (3) Although obesity was found to have a significant individual association with CAD risk factors, obesity per se had no significant direct relationship with the probability of CAD at 10 years. This confirms the conclusion reached by NCEP 11 that obesity caused CAD through the associated risk factors.
PMCID: PMC3444966  PMID: 23008610
Obesity; risk factors of CAD; probability of CAD
19.  Clinical governance and research ethics as barriers to UK low-risk population-based health research? 
BMC Public Health  2008;8:396.
Background
Since the Helsinki Declaration was introduced in 1964 as a code of practice for clinical research, it has generally been agreed that research governance is also needed in the field of public health and health promotion research. Recently, a range of factors led to the development of more stringent bureaucratic procedures, governing the conduct of low-risk population-based health research in the United Kingdom.
Methods
Our paper highlights a case study of the application process to medical research ethics committees in the United Kingdom for a study of the promotion of physical activity by health care providers. The case study presented here is an illustration of the challenges in conducting low-risk population-based health research.
Results
Our mixed-methods approach involved a questionnaire survey of and semi-structured interviews with health professionals (who were all healthy volunteers). Since our study does not involve the participation of either patients or the general population, one would expect the application to the relevant research ethics committees to be a formality. This proved not to be the case!
Conclusion
Research ethics committees could be counter-productive, rather than protecting the vulnerable in the research process, they can stifle low-risk population-based health research. Research ethics in health services research is first and foremost the responsibility of the researcher(s), and we need to learn to trust health service researchers again. The burden of current research governance regulation to address the perceived ethical problems is neither appropriate nor adequate. Senior researchers/academics need to educate and train students and junior researchers in the area of research ethics, whilst at the same time reducing pressures on them that lead to unethical research, such as commercial funding, inappropriate government interference and the pressure to publish.
We propose that non-invasive low-risk population-based health studies such as face-to-face interviews with health and social care professionals or postal questionnaire studies with patients on non-sensitive topics are given a waiver or a light touch review. We suggest that this can be achieved through a two-staged ethics application process. The first stage starts with a one or two-page outline application which ethics committees can use as the basis to grant a waiver or request a full application.
doi:10.1186/1471-2458-8-396
PMCID: PMC2612000  PMID: 19040750
20.  Everyday Ethics: Ethical Issues and Stress in Nursing Practice 
Journal of advanced nursing  2010;66(11):10.1111/j.1365-2648.2010.05425.x.
Aim
This paper is a report of a study of the type, frequency, and level of stress of ethical issues encountered by nurses in their everyday practice.
Background
Everyday ethical issues in nursing practice attract little attention but can create stress for nurses. Nurses often feel uncomfortable in addressing the ethical issues they encounter in patient care.
Methods
A self-administered survey was sent in 2004 to 1000 nurses in four states in four different census regions of the United States of America. The adjusted response rate was 52%. Data were analyzed using descriptive statistics, cross-tabulations and Pearson correlations.
Results
A total of 422 questionnaires were used in the analysis. The five most frequently-occurring and most stressful ethical and patient care issues were protecting patients' rights; autonomy and informed consent to treatment; staffing patterns; advanced care planning; and surrogate decision-making. Other common occurrences were unethical practices of healthcare professionals; breaches of patient confidentiality or right to privacy; and end-of-life decision-making. Younger nurses and those with fewer years of experience encountered ethical issues more frequently and reported higher levels of stress. Nurses from different regions also experienced specific types of ethical problems more commonly.
Conclusion
Nurses face daily ethical challenges in the provision of quality care. To retain nurses, targeted ethics-related interventions that address caring for an increasingly complex patient population are needed.
doi:10.1111/j.1365-2648.2010.05425.x
PMCID: PMC3865804  PMID: 20735502
Ethical issues; stress; nursing practice; patient rights; autonomy; informed consent; survey
21.  Discussing prognosis and end-of-life care in the final year of life: a randomised controlled trial of a nurse-led communication support programme for patients and caregivers 
BMJ Open  2014;4(6):e005745.
Introduction
Timely communication about life expectancy and end-of-life care is crucial for ensuring good patient quality-of-life at the end of life and a good quality of death. This article describes the protocol for a multisite randomised controlled trial of a nurse-led communication support programme to facilitate patients’ and caregivers’ efforts to communicate about these issues with their healthcare team.
Methods and analysis
This NHMRC-sponsored trial is being conducted at medical oncology clinics located at/affiliated with major teaching hospitals in Sydney, Australia. Patients with advanced, incurable cancer and life expectancy of less than 12 months will participate together with their primary informal caregiver where possible. Guided by the self-determination theory of health-behaviour change, the communication support programme pairs a purpose-designed Question Prompt List (QPL—an evidence-based list of questions patients/caregivers can ask clinicians) with nurse-led exploration of QPL content, communication challenges, patient values and concerns and the value of early discussion of end-of-life issues. Oncologists are also cued to endorse patient and caregiver question asking and use of the QPL. Behavioural and self-report data will be collected from patients/caregivers approximately quarterly for up to 2.5 years or until patient death, after which patient medical records will be examined. Analyses will examine the impact of the intervention on patients’ and caregivers’ participation in medical consultations, their self-efficacy in medical encounters, quality-of-life, end-of-life care receipt and quality-of-death indicators.
Ethics and dissemination
Approvals have been granted by the human ethics review committee of Royal Prince Alfred Hospital and governance officers at each participating site. Results will be reported in peer-reviewed publications and conference presentations.
Trial registration number
Australian New Zealand Clinical Trials Registry ACTRN12610000724077.
doi:10.1136/bmjopen-2014-005745
PMCID: PMC4078787  PMID: 24969786
Communication; Cancer; End-of-life care; Advance care planning; Question prompt list; Caregivers
22.  Nurse managers' experience with ethical issues in six government hospitals in Malaysia: A cross-sectional study 
BMC Medical Ethics  2011;12:23.
Background
Nurse managers have the burden of experiencing frequent ethical issues related to both their managerial and nursing care duties, according to previous international studies. However, no such study was published in Malaysia. The purpose of this study was to explore nurse managers' experience with ethical issues in six government hospitals in Malaysia including learning about the way they dealt with the issues.
Methods
A cross-sectional study was conducted in August-September, 2010 involving 417 (69.2%) of total 603 nurse managers in the six Malaysian government hospitals. Data were collected using three-part self-administered questionnaire. Part I was regarding participants' demographics. Part II was about the frequency and areas of management where ethical issues were experienced, and scoring of the importance of 11 pre-identified ethical issues. Part III asked how they dealt with ethical issues in general; ways to deal with the 11 pre-identified ethical issues, and perceived stress level. Data were analyzed using descriptive statistics, cross-tabulations and Pearson's Chi-square.
Results
A total of 397 (95.2%) participants experienced ethical issues and 47.2% experienced them on weekly to daily basis. Experiencing ethical issues were not associated with areas of practice. Top area of management where ethical issues were encountered was "staff management", but "patient care" related ethical issues were rated as most important. Majority would "discuss with other nurses" in dealing generally with the issues. For pre-identified ethical issues regarding "patient care", "discuss with doctors" was preferred. Only 18.1% referred issues to "ethics committees" and 53.0% to the code of ethics.
Conclusions
Nurse managers, regardless of their areas of practice, frequently experienced ethical issues. For dealing with these, team-approach needs to be emphasized. Proper understanding of the code of ethics is needed to provide basis for reasoning.
doi:10.1186/1472-6939-12-23
PMCID: PMC3228789  PMID: 22085735
23.  Knowledge, attitude, and practice of primary health care physicians in the management of osteoarthritis in Al-Jouf province, Saudi Arabia 
Background:
Primary health care (PHC) physicians manage most patients with osteoarthritis (OA). In Saudi Arabia, very little is known about the management of OA by PHC physicians. This study aims to assess knowledge, attitude, and practice of PHC physicians in the management of OA.
Materials and Methods:
During October 2011, a cross-sectional survey was conducted on physicians who were practicing at the primary care centers in AlJouf province of Saudi Arabia. The physicians were asked to fill a valid questionnaire comprised of 35 closed ended questions, 6 items about their socio-demographic characters, and a very well modified 29 questions about their knowledge, attitude, and practice in the management of OA. Data was processed and analysed using SPSS (version 16) program, the level of significance was set as Chi-square test was applied for analysis of categorical data.
Results:
Response rate (77/90=85.6% yielded 77 questionnaires for analysis. The mean ± SD age of respondents was 38 (12.3) years. Majority of the physicians surveyed, 58 (75.3%) considered OA as a common health problem in Saudi Arabia. Only 28 (36.4%) physicians surveyed will achieve continuity of care for OA, whereas more than half (n=44; 57.1%) will refer OA immediately or later to the specialists. The proportion of continuity of care for OA among physicians with diplomas was more than that found among general practitioner (57.1% vs 34.1%; <.05). Only 30 (39%) of physicians appeared to know the radiographic changes associated with OA. 21 (27.3%) of physicians manage an average of 5-10 patients with OA per week. Almost 3/4 th of the physicians (n=57; 74%) prescribe NSAIDs, and only (n=14; 18.2%) prescribe acetaminophen for OA. Less than 1/5 th of the physicians surveyed (n=12; 15.6%) prescribe herbal medicine for OA. Almost all physicians subscribe to regular training programs about OA.
Conclusions:
Appropriate attitude with lack of knowledge was found, and practice of our physicians with regards to this disorder appeared inappropriate. More education focusing on the disorder is recommended.
doi:10.4103/0300-1652.107556
PMCID: PMC3640242  PMID: 23661881
Attitude; continuity of care; knowledge; nonsteroidal anti-inflammatory drugs; osteoarthritis; practice; primary care
24.  Ethical Dimensions of Human Immunodeficiency Virus Infection During Pregnancy 
Physicians encounter complex and sensitive ethical challenges in the medical care of pregnant women with human immunodeficiency virus (HIV) infection. This paper identifies those ethical challenges and provides concrete clinical guidance for how they should be addressed in obstetric care. The paper begins with a brief historical review, to highlight and to call into question the civil rights model of the ethics of HIV infection that has dominated the literature, clinical practice, and public policy. The authors propose an alternative ethical framework. This framework begins by underscoring the public health obligations of both physicians and pregnant women with HIV infection. The framework is based on a clinical ethics that appeals to both beneficence-based and autonomy-based obligations of the physician to the pregnant woman and the beneficence-based obligations of both the physician and the pregnant woman to the fetal patient. This framework is then deployed in a clinical ethical analysis of termination of pregnancy and contraception, partner notification, disclosure and confidentiality of her serostatus by the patient to the health care team, disclosure and confidentiality of her serostatus to other health care professionals, prevention of vertical transmission, and advance directives.
doi:10.1155/S106474499700029X
PMCID: PMC2364565  PMID: 18476174
25.  A systematic review of population-based dental caries studies among children in Saudi Arabia 
The Saudi Dental Journal  2012;25(1):3-11.
Objective
Dental caries critically impacts the health and development of children. Understanding caries experience is an important task for Saudi Arabian policymakers to identify intervention targets and improve oral health. The purpose of this review is to analyze current data to assess the nationwide prevalence and severity of caries in children, to identify gaps in baseline information, and to determine areas for future research.
Methods
A search of published and unpublished studies in PubMed, Google, and local Saudi medical and dental journals was conducted for the three keywords “dental,” “caries,” and “Saudi Arabia.” The inclusion criteria required that the articles were population-based studies that assessed the prevalence of dental caries in healthy children attending regular schools using a cross-sectional study design of a random sample.
Results/discussion
The review was comprised of one unpublished thesis and 27 published surveys of childhood caries in Saudi Arabia. The earliest study was published in 1988 and the most recent was published in 2010. There is a lack of representative data on the prevalence of dental caries among the whole Saudi Arabian population. The national prevalence of dental caries and its severity in children in Saudi Arabia was estimated to be approximately 80% for the primary dentition with a mean dmft of 5.0 and approximately 70% for children’s permanent dentition with a mean DMFT score of 3.5. The current estimates indicate that the World Health Organization (WHO) 2000 goals are still unmet for Saudi Arabian children.
Conclusion
Childhood dental caries is a serious dental public health problem that warrants the immediate attention of the government and the dental profession officials in Saudi Arabia. Baseline data on oral health and a good understanding of dental caries determinants are necessary for setting appropriate oral health goals. Without the ability to describe the current situation, it is not possible to identify whether progress is being made toward these goals. A roadmap with a clear starting point, destination, and pathway is a desperately needed tool to improve the oral health of Saudi Arabian children.
doi:10.1016/j.sdentj.2012.10.002
PMCID: PMC3723279  PMID: 23960549
Oral health; Dental caries; Children; Review; Saudi Arabia

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