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Biomedical subjects

L B McCullough

Publications and source records attributed to L B McCullough.

At least 55 records · Page 3Linked to original sources
PubMed1998

A transcultural, preventive ethics approach to critical-care medicine: restoring the critical care physician's power and authority.

This article comments on the treatment of critical-care ethics in four preceding articles about critical-care medicine and its ethical challenges in mainland China, Hong Kong, Japan, and the Philippines. These articles show how cultural values can be in both synchrony and conflict in generating these ethical challenges and in the constraints that they place on the response of critical-care ethics to them. To prevent ethical conflict in critical care the author proposes a two-step approach to the ethical justification of critical-care management: (1) the decision to resuscitate and initiate critical-care management, which is based on the obligation to prevent imminent mortality without permanent loss of consciousness; and (2) the decision to continue critical-care management, which is based on the obligation both to prevent imminent death without permanent loss of consciousness and to avoid unnecessary, significant iatrogenic costs to the patient and psychosocial costs to the family when the reduction of mortality risk is marginal. Physicians and hospitals should restore the critical-care physician's authority and power -- against prevailing cultural values, if necessary -- to control when critical-care intervention is offered, when it is recommended to continue, and when it is recommended to be discontinued and the patient allowed to die.

Beneficence↗
PubMed1998

Should all pregnant women have an ultrasound examination?

This paper addresses the question whether all pregnant women should have an ultrasound examination. We used the methods of ethical analysis and argument to show that the principle of respect for autonomy creates an obligation to inform every pregnant woman about the availability of obstetric ultrasound in settings in which quality ultrasound is available. We considered two objections to this position, lack of benefit and excessive costs, and showed that these objections did not succeed. Obstetricians throughout the world should be advocates for informing pregnant women about the availability of routine obstetric ultrasound.

Ethics, Medical↗
PubMed1998

Ethical issues in gynecology.

The authors apply the language and concepts of ethics to the problem of differences between the gynecologist and the patient about what is in the patient's interest. We develop a framework for clinical judgment and decision making about the ethical dimensions of the gynecologist-patient relationship. To achieve this goal we define the ethical principles of beneficence and respect for autonomy. We then show how these two principles interact in clinical judgement and decision making using common examples from gynecologic practice. We examine factors that influence the relative weight of these principles, including subject matter, probability of net medical benefit, availability of reasonable alternatives, and ability of the patient to participate in the informed consent process.

Beneficence↗
PubMed1997

Ethically justified, clinically comprehensive guidelines for percutaneous endoscopic gastrostomy tube placement.

Guidelines for the placement of percutaneous endoscopic gastrostomy (PEG) tubes are not available. We developed a decision-making algorithm by integrating the medical and ethical dimensions of the decision. According to our algorithm, physicians should not offer PEG tubes to patients with anorexia-cachexia syndromes. For patients with permanent vegetative states, physicians should offer and recommend against the procedure. For patients who have dysphagia without other deficits in quality of life, physicians should offer and recommend the procedure. For the the remaining patients who have dysphagia with other deficits in quality of life, the physician's role is to provide non-directive counselling regarding the short and long-term consequences of a trial of PEG tube feeding.

Algorithms↗
PubMed1997

Ethics in obstetrics and gynecology. An overview.

This paper provides an overview of ethical issues in obstetrics and gynecology. We first define two basic ethical principles, beneficence and respect for autonomy. We first apply these principles to gynecologic practice, emphasizing the role of informed consent. We then apply these principles to obstetric practice, utilizing the concept of the fetus as a patient and identifying its clinical implications for directive versus non-directive counseling for fetal benefit.

Beneficence↗
PubMed1997

The management of instability and incompleteness: clinical ethics and abstract expressionism.

Central concepts and consensus views in clinical ethics are marked by instability. The papers in this number of the Journal take up two such central concepts, quality of life and moral status, and two such consensus views, that germ-line gene transfer should not be undertaken for the purposes of enhancement of human traits and that the ethical obligation of physicians to treat HIV-infected patients rests on consent of the physician. One outcome of these philosophical investigations is that these two concepts and consensus views are less stable than one might have thought. I explore the possibility of generalizing this outcome in a reflection on clinical ethics as the management of instability and incompleteness, including the instability and incompleteness of clinical ethics itself. In the course of this reflection I liken clinical ethics to abstract expressionism in mid-twentieth century Western art.

Bioethical Issues↗
PubMed1997

Clinical implications of respect for autonomy in the psychiatric treatment of pregnant patients with depression.

Major depression, as well as depressive symptoms that do not meet the full diagnostic criteria for a diagnosis of depression, can chronically and variably affect a woman patient's decisions about the management of pregnancy, including the decision about whether to continue a pregnancy. Depression also has potential adverse consequences for the pregnant woman and her pregnancy. However, little attention has been given to the ethical challenges posed by the psychiatric management of depression during pregnancy. The psychiatrist should balance respect for the autonomy of the depressed woman with beneficence-based obligations to the pregnant woman, and also to the fetus, when the fetus is viable. The authors recommend strategies for assessing the decision-making abilities of pregnant patients with depression and for enhancing their autonomy. They suggest that nondirective counseling should generally be used with pregnant patients with depression when the fetus is previable and that directive counseling is ethically justifiable when the fetus is viable.

Abortion, Induced↗
PubMed1997

The limits of viability.

We provide an ethical analysis of the divergence of mortality and potential morbidity in very premature infants. Based on this ethical analysis we conclude that at this time viability should be at 24 weeks or greater and not at 23 weeks.

Beneficence↗
PubMed1996

An ethically justified algorithm for offering, recommending, and performing cesarean delivery and its application in managed care practice.

When cesarean delivery is substantively supported and vaginal delivery is not supported in beneficence-based clinical judgment, the physician should offer and recommend only cesarean delivery. When both cesarean and vaginal delivery are substantively supported in beneficence-based clinical judgment, the physician should offer both, discuss any controversy, and make a recommendation. When cesarean delivery is substantively supported and vaginal delivery is more substantively supported in beneficence-based clinical judgment, the physician should offer both and recommend vaginal delivery. If cesarean delivery is not supported and vaginal delivery is substantively supported in beneficence-based clinical judgment, the physician should offer only vaginal delivery. When cesarean delivery is requested and well supported solely in autonomy-based clinical judgment, the physician should repeat the recommendation for vaginal delivery and either perform cesarean delivery or make a referral. Physicians may use this algorithm in negotiating managed care contracts.

Algorithms↗
PubMed1996

Cesarean delivery for intrapartum fetal heart rate abnormalities: incorporating survey data into clinical judgment.

OBJECTIVE: To identify the descriptive clinical practice of maternal-fetal medicine specialists when faced with severe intrapartum fetal heart rate (FHR) abnormalities (as determined by continuous electronic fetal monitoring). METHODS: All regular members of the Society of Perinatal Obstetricians (maternal-fetal medicine specialists) were sent a survey questionnaire on the topic of cesarean delivery for intrapartum FHR abnormalities. The time from observation of FHR abnormalities to making the decision to proceed to cesarean delivery was the main outcome measure. Time was allowed for intrauterine resuscitative maneuvers to alleviate the abnormal pattern. Legislative definitions of consensus and strong consensus were applied to the data. Analysis of covariance was performed to determine the effect of physician demographic factors on the times reported. RESULTS: Four hundred thirty-one of 704 (61.2%) questionnaires were returned. Consensus was identified for deciding on cesarean delivery (after intrauterine resuscitation) 1) after 30 minutes for cases of repetitive late and severe variable decelerations, 2) after 10 minutes in cases of fetal bradycardia, and 3) in all scenarios with decreased beat-to-beat variability of the FHR. Consensus was identified for deciding on cesarean delivery in five of eight intrapartum FHR pattern abnormalities. CONCLUSION: The descriptive clinical practice of maternal-fetal medicine specialists demonstrated in this study should be considered in prudential clinical judgment.

Arrhythmias, Cardiac↗
PubMed1996

The impact of routine obstetric ultrasonographic screening in a low-risk population.

OBJECTIVES: Our goal was to develop a framework for evaluating the current controversy regarding routine obstetric ultrasonography in a population of low-risk pregnancies. STUDY DESIGN: A retrospective chart review was performed for all low-risk pregnancies from a single obstetric practice during 1990 to 1994, to determine the accuracy of screening ultrasonography for fetal anomalies. All patients received a routine ultrasonographic examination at 18 to 20 weeks' gestation. Neonatal records for all patients were evaluated for the presence of both major and minor anomalies. The data were analyzed with attention to the classification of anomalies (all anomalies vs major anomalies, detectable vs nondetectable). RESULTS: A total of 860 fetuses in 854 pregnancies were evaluated. Anomalies were present in 5.35% (46/860); these were major anomalies in 1.16% (10/860) and minor anomalies in 4.19% (36/860). The sensitivity, specificity, and positive and negative predictive values for the diagnosis of all anomalies were 8.7%, 99.9%, 80%, and 95.7%, respectively. However, if only major anomalies detectable by ultrasonography are included, these values become 75%, 100%, 100%, and 99.9%, respectively. There was one false-positive diagnosis not affecting outcome, a small ventriculoseptal cardiac defect. Postnatal ascertainment of anomalies was excellent, as determined by an incidence of ventriculoseptal defects of 1 in 120. CONCLUSION: Distinguishing between major and minor anomalies and between ultrasonographically detectable versus nondetectable anomalies is essential in the evaluation of the diagnostic accuracy of screening ultrasonography. Any comparisons of studies examining the effectiveness of prenatal screening for congenital anomalies with ultrasonography should use the same outcome: major anomalies identifiable by ultrasonography.

Congenital Abnormalities↗
PubMed1996

Ethically justified guidelines for defining sexual boundaries between obstetrician-gynecologists and their patients.

OBJECTIVE: This article proposes ethically justified guidelines that should govern the ethical obligations of obstetrician-gynecologists when they experience sexual feelings toward patients. STUDY DESIGN: We reviewed literature on physician-patient sexual contact and related that literature to ethical principles. RESULTS: Existing guidelines that prohibit sexual contact between physicians and patients are based on an ethical argument that such relationships violate the ethical principles of respect for both autonomy and beneficence. This argument is incomplete because patients can provide valid consent for sexual relationships with their own obstetrician-gynecologists. CONCLUSION: We propose a virtues-based ethical argument that is independent of informed consent for governing sexual relationships between obstetrician-gynecologists and their patients. In the context of the physician-patient relationship the professional virtues of self-effacement and self-sacrifice obligate the obstetrician-gynecologist to set aside and never act on feelings of sexual attractiveness toward patients.

Ethics, Medical↗
PubMed1996

Ethically justified clinically comprehensive guidelines for the management of the depressed pregnant patient.

OBJECTIVE: This article proposes ethically justified clinical guidelines for managing depressed patients during pregnancy. STUDY DESIGN: We reviewed literature on depression and its consequences for pregnancy and related that literature to ethical principles. RESULTS: The health effects of depression on the pregnant woman and her fetus cannot be managed without consideration of the chronic and variable impairment of autonomy that may result from the effects of depression on the pregnant woman's decision-making capacity. CONCLUSION: When the fetus is previable, recommendations concerning the disposition and prenatal diagnosis of the pregnancy should be nondirective, whereas strong treatment recommendations are justifiable if the pregnant woman has decided to continue her pregnancy and is severely depressed. After viability, directive counseling for fetal benefit is ethically justified. The guidelines focus on preventive ethics strategies to enhance the decision-making capacity of the depressed pregnant patient.

Beneficence↗