The ethics of surrogate decision making in medicine : autonomy, paternalism, or a different approach?

Knowing who to involve in treatment decisions when a patient is incapacitated has been the subject of discussion in bioethical, health law and clinical research. The major issues tend to revolve around the tension between exercising a degree of medical paternalism and respecting patient autonomy. Patients are encouraged to exert their autonomy even when they may not be capable of doing so, by means of surrogate consent or advanced directives. While liberal concepts of autonomy are exemplified in western bioethics and legal systems, clinically these decisions remain difficult, and input from medical professionals is sought, raising the issue of paternalism. A framework of bioethics, which places the patient in a relational context rather than a strictly autonomous one, may be a more helpful way of deliberating these difficult decisions

Renegade judgement : a study of madness in medicine and literature

Explores socio-historical understandings and treatments of madness, examining literary works alongside contemporary medical texts. Incorporating notions of scientific objectivity, individual subjectivity and social totality, the thesis shows conceptual overlaps between art and science, identifying continuities and conflicts between fictional, clinical and cultural investigations into madness.

Maternity care experiences of Asia ethnic minorities in rural Tasmania, Australia : a mixed methods study

When migrating to Australia Asian women bring with them birthing cultural beliefs and practices, many of which are different from the Australian medical and cultural understanding of reproduction. Such cultural differences may result in conflicts between clients and health care providers especially when the migrants have a poor knowledge of English. The research investigates the maternity care experiences of Asian migrants in Tasmania. The barriers that Asian migrants face in accessing maternity care services and the factors that affect their views towards maternity care were also explored. A mix of quantitative and qualitative methods was employed. Ten women from different ethnic minorities were invited to semi-structured interviews. The qualitative data were analysed using grounded theory. Findings from the interviews were utilized to design a survey questionnaire. Of the 150 survey questionnaires posted, 121 questionnaires were returned. Descriptive statistics and Chi-square tests of independence were used to analyse the quantitative data. Asian migrants followed some traditional practices such as having good rest and eating hot food during the postpartum month. However, they tended to adapt or disregard traditional practices that were no longer applicable in the new environment including the practices of not washing or having a shower. Support is vital for women recovering after childbirth to prevent postnatal depression. Two main barriers migrant women face in accessing health care are language and cultural barriers. Country of origin, partner’s ethnicity, religion and length of stay in Australia are factors that shape the migrants’ views and attitudes towards and experience of maternity care. Providing interpreting services, social support for migrant women and improving the cross-cultural training for healthcare providers are recommended to improve available maternal care services. The factors that affect migrants’ view on maternity care should be taken into account when providing maternity care for Asian migrant women.

Understanding quality of life in medicine : a new approach

This article introduces the subjective side of quality of life as it has evolved within the discipline of psychology. Subjective well-being is also of special interest within medicine due to its links to pathology and the fact that it is managed by a homeostatic system. This form of management offers an explanation for the unusual properties of subjective well-being, including its normal positivity, stability, and nonlinear relationship to objective variables, such as physical health. Central to understanding is the proposition that subjective well-being mainly consists of a specific form of trait mood. This homeostatically protected mood has a genetic set point and it is the experience of this set-point mood that homeostasis is defending. The resources required to maintain normal homeostatic control are described. If these resources are inadequate to protect the experience of set-point mood, mood positivity falls, and there is a high probability of depression. In this article, the process of homeostasis is shown to assist understanding of intervention effectiveness within both psychology and medicine. This concerns matters of resilience, the nonlinear relationship between levels of subjective well-being, and the strength of challenging agents, and the important understanding that interventions designed to raise subjective well-being are critically dependent on its level at baseline. Key teaching points: • The physiological process of homeostasis has a parallel in psychology in the homeostatic management of subjective well-being. • Subjective well-being is a more globally informative construct than health-related quality of life. • How people feel about themselves and their lives cannot be simply predicted through measures of health. • When subjective well-being homeostasis is defeated, there is a high probability of depression.

Causation in law and medicine

Causation is an issue that is fundamental in both law and medicine, as well as the interface between the two disciplines. It is vital for the resolution of a great many disputes in court concerning personal injuries, medical negligence, criminal law and coronial issues, as well as in the provision of both diagnoses and treatment in medicine. This book offers a vital analysis of issues such as causation in law and medicine, issues of causal responsibility, agency and harm in criminal law, causation in forensic medicine, scientific and statistical approaches to causation, proof of cause, influence and effect, and causal responsibility in tort law

Reporting and the politics of difference : (non) disclosure on ethnic minorities

This article is based on two related research questions. First, what is the level of disclosure on ethnic minorities in the two sectors of the U.K. economy that historically have employed the most ethnic minorities: the banking and retail sectors? And secondly, what influences the (non)disclosure? It specifically investigates the level of disclosures from 1935 to 1998 and situates them within the changing social, political and economic context of this period. It is contended that the changing pattern of disclosure during this period can be understood with reference to changes in the political strategies for managing the threat of racism adopted by successive governments. The article provides some tentative theoretical reflections on the nature of the racism problematic and the way in which power may be seen to operate through (non)disclosure in this particular instance.

Intertester reliability of sonography in patellar tendinopathy

Objective. Intertester reliability is imperative during the sonographic assessment of patellar tendinopathy because hypoechoic areas can change over time, and repeated examination may involve multiple examiners. Given that, to our knowledge, it has not been reported in the literature, the objective of this study was to investigate the intertester reliability of sonography for the detection and measurement of hypoechoic areas associated with patellar tendinopathy.

Methods. The study cohort comprised 8 patients with clinically diagnosed patellar tendinopathy and 4 patients with bilateral asymptomatic patellar tendons. Two equally experienced musculoskeletal radiologists imaged both patellar tendons from each patient (n = 24). All 24 tendons were assessed on the same day with the use of identical sonography machines.

Results. The radiologists had 100% chance-corrected agreement for detecting 12 normal (hypoechoic free) and 12 abnormal (hypoechoic) tendons. All measurement data were normally distributed (P > .05), and a range of hypoechoic area sizes was evident. No statistically significant differences were found for the measurements of hypoechoic area, axial plane height and width, and sagittal plane height (P > .05). In addition, these measurements were equally highly correlated (Pearson r > 0.87; P < .01).

Conclusions. The results reported in this study suggest that the intertester
reliability of sonography for the assessment of patellar tendinopathy is high. Although these results are encouraging, a small sample was analyzed, and this increases the probability of type II measurement error. Larger studies are therefore required to confirm these findings. High intertester reliability indicates that multiple experienced radiologists can reliably assess the same tendon and provides researchers with a necessary foundation for furthering research in tendon rehabilitation.

Action research in health promotion

Objectives This article aims to define what is action research and where it fits in with health promotion practice, through drawing upon associated literature and personal action research experience. It also seeks to investigate the possible reasons why it is that health promotion researchers have not readily taken on the processes of action research strategies.

Rationale The place of action research in health promotion programmes is an important yet relatively unacknowledged and understated activity. It has proven to be very popular with other professional groups, such as in the education, management and social sciences. In terms of health service activity, it is widely established in the fields of nursing and mental health and is beginning to establish itself in medicine. While there are a few health promotion examples to draw upon, they tend to be isolated, dated and often lie outside of the mainstream literature. It is suggested that this continuing state of affairs denies many health promotion researchers a valuable resource for managing effective change in practice.

Conclusion The authors suggest that action research is both a valid and
important research method for health promotion researchers, who are advised to further consider its merits in future studies. This article draws attention to the National Health Service (NHS) South West Regional Office-commissioned Our Healthier Nation: Improving the Competence of the Workforce in Health Promotion participatory action research project, as a means of promoting and validating action research strategy. The authors were all actively involved in this project.

What's needed to increase research capacity in rural primary health care

The aim of this study is to identify ways to build research capacity within primary health. A consultation was undertaken in late 2004 using a combination of a one-page survey and a guided meeting format, in a primary health setting in rural NSW. Most (81.3%) of the 134 individuals consulted were part of an Area Health Service, with 12.7% from non-government settings. Most (80.6%) were clinicians, with a third (31.5%) nurses, 8.3% in medicine, and the remainder from a range of allied health professions. Eleven organisations were represented. The main  outcome measures were identification of support needs, processes to enhance research engagement, and barriers and enablers to clinicians’ research  involvement. The results showed that popular delivery modes for research training and support were courses and “one-to- one” advice. Writing topics were generally more popular than others. Common barriers were time and technology issues. A key enabler was a discipline-specific focus. This is one of few rural Australian  consultations on research needs in primary health conducted with a diverse  range of clinicians at the clinician level. It will direct future research capacity  building efforts towards maximising face-to-face discipline specific options and  minimising technology use.

History of contact and change in the Goroka Valley, Central Highlands of New Guinea, 1934-1949

The thesis traces the interaction of the Goroka Valley people with European and coastal New Guinean intruders during the pacification stage of contact and change. In this 15 year period the people moved from a traditional subsistence culture to the threshold of a modern, European-influenced technological society. The contact experiences of the inhabitants of the Valley and the outsiders who influenced them are examined, using both oral and documentary sources. A central theme of this study is the attempts by Europeans and their coastal New Guinean collaborators to achieve the pacification of a people for whom warfare has been described as 'the dominant orientation'. The newcomers saw pacification as being inextricably linked with social, economic and religious transformation, and consequently it was pursued by patrol officers, missionaries and soldiers alike. Following an introductory chapter outlining the pre-contact and early-contact history of the Goroka Valley people, there is a discussion of the causes of tribal fighting in Highlands communities and two case studies of violent events which, although occurring beyond the Goroka Valley, had important consequences for those who lived within its bounds. The focus then shifts to the first permanent settlement of the agents of change -initially these were coastal New Guinean evangelists and policemen - and their impact on the local people. A period of consolidation is then described, as both government and missions established a permanent 'European presence in the Valley'. This period was characterised by vigorous pacification coupled with the introduction of innovations in health and education, agriculture, technology, law and religion. The gradual transformation of Goroka Valley society as a result of the people's interaction with the newcomers was abruptly accelerated in 1943, when many hundreds of Allied soldiers occupied the Valley in anticipation of a threatened Japanese invasion. Village life was disrupted as men were conscripted as carriers and labourers and whole communities were obliged to grow food to assist the Allied war effort. Those living close to military airfields-and camps were subject to Japanese aerial attacks and the entire population was exposed to an epidemic of bacillary dysentery introduced by the combatants. However the War also brought some positive effects, including paradoxically, the almost total cessation of tribal fighting, the construction of an ail-weather airstrip at Goroka which ensured its future as a town and administrative and commercial centre, and the compulsory growing of vegetables, coffee, etc, which laid the foundations for a cash economy and material prosperity. The final chapter examines the aftermath of military occupation, the return of civil administration and the implementation of social and economic policies which brought the Goroka Valley people into the rapid-development phase of contact. By 1949 Gorokans were ready to channel their aggressive energies into commercial competitiveness and adopt a cash-crop economy, to accept the European rule of law, to take advantage of Western innovations in medicine, education, transport and communications, to seek employment opportunities at home and in other parts of the country and to modify their primal world view with European religious and secular values. A Stone Age people was in process of being transformed into a modern society.

Interpersonal features of talk in interpreted medical consultations

This linguistic study examined the interpersonal features of the talk between doctors and patients in consultations where a professional medical interpreter was required for them to communicate. Such features affect the relationship between doctor and patient and can impact on medical outcomes. The findings will assist interpreters and doctors in talking to patients and forms part of a larger project to develop a theory of medical interpreting.

Is diagnosis enough to guide interventions in mental health? Using case formulation in clinical practice

While diagnosis has traditionally been viewed as an essential concept in medicine, particularly when selecting treatments, we suggest that the use of diagnosis alone may be limited, particularly within mental health. The concept of clinical case formulation advocates for collaboratively working with patients to identify idiosyncratic aspects of their presentation and select interventions on this basis. Identifying individualized contributing factors, and how these could influence the person's presentation, in addition to attending to personal strengths, may allow the clinician a deeper understanding of a patient, result in a more personalized treatment approach, and potentially provide a better clinical outcome.