Background: Discussing treatment risks has become increasingly important in medical communication. Still, despite regulations, physicians must decide how much and what kind of information to present. Objective: To investigate patients’ preference for information about a small risk of a complication of colonoscopy, and whether medical and personal factors contribute to such preference. To propose a disclosure policy related to our results. Design: Vignettes study. Setting: Department of Gastroenterology, Academic Medical Centre, the Netherlands. Patients: 810 consecutive colonoscopy patients. Intervention: A home-sent (...) questionnaire containing three vignettes. Vignettes varied in the indication for colonoscopy, complication severity and level of risk. Patients were invited to indicate their wish to be informed and the importance of such information. In addition, sociodemograhic, illness-related and psychological characteristics were assessed. Main outcome measurements: Wish to be informed and importance of information. Results: Of 810 questionnaires, 68% were returned. Patients generally wished to be informed about low-risk complications, regardless of the indication for colonoscopy or the severity of the complication. The level of risk did matter, though (OR = 2.48, SE = 0.28, p = 0.001). The information was considered less important if done for population screening purposes or diagnosis of colon cancer, if the complication was less severe (bleeding) and if the risk was smaller (0.01% and 0.1%). Patients’ information preference was also related to age, mood and coping style. Limitations: Difficulty of vignettes. Conclusions: Patients generally wish to be informed about all possible risks. However, this might become uninformative. A stepwise approach is suggested. (shrink)

BackgroundIn the Canadian Alliance for Healthy Hearts and Minds (CAHHM) cohort, participants underwent magnetic resonance imaging (MRI) of the brain, heart, and abdomen, that generated incidental findings (IFs). The approach to managing these unexpected results remain a complex issue. Our objectives were to describe the CAHHM policy for the management of IFs, to understand the impact of disclosing IFs to healthy research participants, and to reflect on the ethical obligations of researchers in future MRI studies.MethodsBetween 2013 and 2019, 8252 participants (...) (mean age 58 ± 9 years, 54% women) were recruited with a follow-up questionnaire administered to 909 participants (40% response rate) at 1-year. The CAHHM policy followed a restricted approach, whereby routine feedback on IFs was not provided. Only IFs of severe structural abnormalities were reported.ResultsSevere structural abnormalities occurred in 8.3% (95% confidence interval 7.7–8.9%) of participants, with the highest proportions found in the brain (4.2%) and abdomen (3.1%). The majority of participants (97%) informed of an IF reported no change in quality of life, with 3% of participants reporting that the knowledge of an IF negatively impacted their quality of life. Furthermore, 50% reported increased stress in learning about an IF, and in 95%, the discovery of an IF did not adversely impact his/her life insurance policy. Most participants (90%) would enrol in the study again and perceived the MRI scan to be beneficial, regardless of whether they were informed of IFs. While the implications of a restricted approach to IF management was perceived to be mostly positive, a degree of diagnostic misconception was present amongst participants, indicating the importance of a more thorough consent process to support participant autonomy.ConclusionThe management of IFs from research MRI scans remain a challenging issue, as participants may experience stress and a reduced quality of life when IFs are disclosed. The restricted approach to IF management in CAHHM demonstrated a fair fulfillment of the overarching ethical principles of respect for autonomy, concern for wellbeing, and justice. The approach outlined in the CAHHM policy may serve as a framework for future research studies.Clinical trial registrationhttps://clinicaltrials.gov/ct2/show/nct02220582. (shrink)

Possible distributive justice frameworks for providing health care by general practitioners are discussed. The ethical considerations before and after the recent changes to the British National Health Service are contrasted, with particular emphasis on a possible ethical divide that has been produced between fund-holding and non-fund-holding general practitioners. It is argued that general practitioners in non-fund-holding practices can continue as ethical advocates for their patients and distribute health care within an egalitarian framework. However, those in fund-holding practices may now be (...) seen as interest advocates and may have to practise utilitarian distributive justice. Patient groups may be needed to ensure that these general practitioners are seen to act justly in the distribution of the health care resources for which they are now responsible. (shrink)

The relation between Jesus and the Spirit appears in diverse occasions and in different contexts in Gregory. Jesus has sanctified the waters in his baptism, from his body springs the Spirit whom he has received in the Jordan, he is the «anointed», the «Christ» par excellence who gives the Holy Spirit to people at Pentecost. The theology of the baptism of the Lord calls for special attention; it takes place at an interesting moment of transition. On the one hand, the (...) effusion of the Spirit on the humanity of Jesus does not create any problem for Gregory who distinguishes it clearly from the incarnation of the Son. On the other hand, the initiative of the Father in this unction is not paid special attention to, nor does it seem that it has a special significance for Jesus himself and the beginning of his mission in the world. However, much stress is given to the ecclesiological dimension of the descent of the Spirit in the baptism of Christ. On him comes the Spirit in fullness, as he will also abide in fullness in the whole Church which is his Body. Each of the Christians receives only a partial gift which must contribute to the perfection of the whole. (shrink)

IntroductionThe identity thesis asserts that for every psychological state P there is a neural state N such that P=N. In the hope of rendering IT clear and plausible many identity theorists have compared psycho-neural identity claims to such theoretical identities as temperature is identical with molecular mean kinetic energy. However such a comparison admits a weak and a strong interpretation. According to the weak interpretation, psycho-neural identities are said to be like theoretical identities in the sense that the former are (...) contingent claims just as the latter are presumed to be. Identity theorists have appealed to the contingent status of IT in order to meet prima facie objections of the following sort. We can imagine ourselves undergoing a pain, although we are not undergoing the neural process which the identity theorist claims is identical with the pain. Indeed we can imagine ourselves being in pain and yet not having a brain at all. Hence IT is false. Identity theorists have replied by arguing that this objection merely shows that IT is not a necessary truth, or that psychological and neurological terms do not have the same meaning. (shrink)

This article is an attempt to evaluate the Oregon plan from the perspective of a Scandinavian national health care system. The Nordic welfare states are marked by a strong emphasis on equality. As an example of an egalitarian system we present the Norwegian health care model in part one. In part two, the arguments in favor of a one tier system in Norway are presented and compared to Oregon's two tier system. Although we argue, in part three, that a comparison (...) of the degree of explicitness in the prioritization process shows that Norway has much to learn from Oregon, we do believe that the Norwegian system has some attractive elements that may function as an important corrective. In part four we present the Norwegian Guidelines for priority-setting and discuss the weight assigned to the severity of disease criterion. It is argued that the exclusion of information about the severity of disease partly explains the counterintuitive ranking of treatment-condition pairs in Oregon's initial method based on the principle of health maximization. A normative analysis of the conflicting norms of efficiency and equality of results is called for. The final part of the paper is devoted to the problem of rigidity. Henry J. Aaron has argued that the Oregon system is insensitive to inter-individual variations within each diagnosis-treatment pair. This objection is a severe one, since the system might end up treating patients unfairly on the individual level. To overcome this problem, we suggest a selection rule that should be more capable of dealing with the problem of rigidity. (shrink)

In the anthropology of Gregory of Elvira there converge different lines of thought. On the one hand he is very dependent on Origen, on the other there is to be found in him the mental framework of Irenaeus and he quotes word for word long passages from Tertullian. The article attempts to determine to what extent, starting from those influences he encountered, Gregory has developed a personal vision of the relationship between Adam and Christ along the double line of the (...) Pauline parallel : sin and grace, initial creation and eschatological fulfilment. If some characteristic passages stress much this second aspect, the majority of the texts analyzed concentrate primarily on the theme of redemption. The reason for the prefiguration of Christ in the creation of Adam, so important for Irenaeus and Tertullian, does not have in Gregory the prominent place which one might have expected to find. (shrink)