Bioethics for clinicians, revisited
From July 1996 to October 1998 CMAJ published a series of articles discussing important aspects of contemporary bioethics. In this issue we present the first of a new set of articles that extend into such previously unvisited terrain as the disclosure of medical error and the determination of brain death. Articles on Aboriginal, Hindu and Sikh, Chinese, Islamic, Jewish and Christian beliefs will explore how cultural perspectives and religious values can affect medical decision-making. In the first article, Jonathan Ellerby and colleagues discuss the difficulties of applying non-Aboriginal bioethical notions in the context of Aboriginal culture, a context that is itself diverse and pluralistic. The authors describe how values such as holism, autonomy and an emphasis on quality of life may come into play in the health care decisions of Aboriginal patients, and they emphasize the importance of using appropriate communication styles and of understanding the interpersonal and situational dimensions of the decision-making process.
See pages 833 and 845
The limitations of evidence-based medicine
The term ”evidence-based medicine” is less than 10 years old, although the underlying concept predates it. It is a subject of increasing interest and some controversy. Sharon Straus and Finlay McAlister have reviewed published criticisms of evidence-based medicine. Some problems are intrinsic to the practice of medicine, such as the variable quality of evidence and the difficulty in applying the results of a trial to the care of an individual patient. Others, such as the need for busy clinicians to acquire new skills and to spend time seeking information, should be addressed through established educational forums and new technologies. Many criticisms result from misperceptions, which may be addressed by careful attention to the definition and intent of evidence-based medicine.
See page 837
Tuberculosis in immigrants
The immigrant population in Canada and other developed countries is known to be at risk for tuberculosis. Wendy Wobeser and colleagues have analyzed data from the Ontario Reportable Disease Information Service and the Citizenship and Information database to identify higher risk groups within this population. They report that the 2 strongest determinants of risk are referral for medical surveillance by immigration officials and world region of origin. Advanced age and lower socioeconomic status were independently associated with increased risk.
See page 823
Perinatal transmission of HIV
Joan Robinson and Bonita Lee have reviewed records for 71 children born in northern Alberta to 54 HIV-positive women from January 1988 to December 1999. HIV infection was diagnosed before labour in 43 women. A subgroup of women received antiretroviral agents both during pregnancy and intrapartum; 86% (31/36) of their babies were not HIV positive. Except for 2 infants, all received at least some zidovudine orally in the first 6 weeks of life. Most (68%) of the children in the study were Aboriginal. The high rate of concurrent hepatitis C (62%) among the Aboriginal mothers suggests that injection drug use is an important risk factor for Aboriginal women in northern Alberta.
See page 831
Osteoporosis and fragility fractures
Fracture is the first symptom of previously undiagnosed osteoporosis. Ernest Hajcsar and colleagues report on their survey of 228 patients who had presented to Ontario fracture clinics with fractures associated with bone fragility. Of the 108 eligible patients who responded, only 20 (18.5%) had received a diagnosis of osteoporosis either before or within 1 year of the fracture and 43 (39.8%) had experienced previous fractures. Of the 20 who received a diagnosis of osteoporosis, 8 (40%) were taking hormone replacement therapy and 8 (40%) were taking bisphosphonates; the corresponding numbers among those undiagnosed were 4 (4.5%) and 0. Since osteoporosis is a disease with significant morbidity and mortality, effective intervention represents a major public health opportunity.
See page 819
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