Background: More and more quantitative information is becoming available about the risks of complications arising from medical treatment. In everyday practice, this raises the question whether each and every risk, however low, should be disclosed to patients. What could be good reasons for doing or not doing so? This will increasingly become a dilemma for practitioners.Objective: To report doctors’ views on whether to disclose or withhold information on low risks of complications.Methods: In a qualitative study design, 37 respondents were included. (...) Focus group interviews were held with 22 respondents and individual in-depth interviews with 15.Results: Doctors have doubts about disclosing or withholding information on complication risk, especially in a risk range of 1 in 200 to 1 in 10 000. Their considerations on whether to disclose or to withhold information depend on a complicated mix of patient and doctor-associated reasons; on medical and personal considerations; and on the kind and purpose of intervention.Discussion: Even though the degree of a risk is important in a doctor’s considerations, the severity of the possible complications and patients’ wishes and competencies have an important role as well. Respondents said that low risks should always be communicated when there are alternatives for the intervention or when the patient may prevent or mitigate the risk. When the appropriateness of disclosing risks is doubtful, doctors should always tell their patients that no intervention is without risk, give them the opportunity to gather all the information they need or want, and enable them to detect a complication at an early stage. (shrink)

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)

Artikelen en lezingen uit de periode 1970-1982.

Deze korte studie biedt niet de zoveelste inleiding in het denken van Spinoza, maar doet verslag van de persoonlijke, vijfentwintig jaar durende zoektocht om de vaak moeilijke thema's van Spinoza onder de knie te krijgen. Om via Spinoza's filosofie meer te begrijpen van de wereld en van het eigen leven. Om de vreugde te ervaren die dit verbeterde inzicht, in oorzaken en gevolgen, en ook in de eigen beperktheid, ons biedt. Elk hoofdstuk gaat over een onderwerp dat de auteur bijzonder (...) aanspreekt. Bestaat er een levenswil, Spinoza's conatus, die mensen voort doet leven ook onder de meest bittere omstandigheden? Is kennis en inzicht gradueel van aard? Wat is het verschil tussen adequate en inadequate kennis van de oorzaken van ons handelen? Hoe ontwikkelt een machtsstaat zich tot een rechtsstaat? (shrink)

Ethics support services like Moral Case Deliberation intend to support healthcare professionals in ethically difficult situations. To assess outcomes of MCD, the Euro-MCD Instrument has been developed. Field studies to test this instrument are needed and have been conducted, examining important outcomes before MCD participation and experienced outcomes. The current study aimed to describe how participants’ perceive the importance of MCD outcomes after MCD; compare these perceptions with those before MCD participation; and test the factor structure of these outcomes. Swedish, (...) Norwegian and Dutch healthcare professionals rated the importance of outcomes in the Euro-MCD Instrument after four and eight MCDs. Ratings were compared with those before MCD participation using paired and independent samples t-tests. The factor structure was tested using exploratory factor analyses. After 4 and 8 MCDs, 443 respectively 247 respondents completed the instrument. More than 69% rated all MCD outcomes as ‘quite’ or ‘very’ important, especially outcomes from Enhanced Collaboration, Improved Moral Reflexivity and Improved Moral Attitude. Significant differences for 16 outcomes regarding ratings before and after MCD participation were not considered meaningful. Factor analyses suggested three categories, which seemingly resemble the domains Improved Moral Reflexivity, Enhanced Collaboration and a combination of Improved Moral Attitude and Enhanced Emotional Support. After participation in MCDs, respondents confirmed the importance of outcomes in the Euro-MCD Instrument. The question on perceived importance and the categorization of outcomes need reconsideration. The revised instrument will be presented elsewhere, based on all field studies and theoretical reflections. (shrink)

In their environment, plants are continuously submitted to natural stimuli such as wind, rain, temperature changes, wounding, etc. These signals induce a cascade of events which lead to metabolic and morphogenetic responses. In this paper the different steps are described and discussed starting from the reception of the signal by a plant organ to the final morphogenetic response. In our laboratory two plants are studied: Bryonia dioica for which rubbing the internode results in reduced elongation and enhanced radial expansion and (...) Bidens pilosa for which the response occurs at distance, hence pricking the cotyledon of a plantlet induces the growth inhibition of both the hypocotyl and the axillary bud of the pricked cotyledon. Reception of the signal and transmission of the message. In Bryonia the signal is received by epidermal cells while in Bidens they are the cells adjacent to the midrib of the cotyledon which receive the mechanical signal. In both plants the message is transmitted via a wave of electric depolarization. This latter is composed of an action potential associated with a slow wave whose transmission rates are respectively 1cm s−1 and 1 mm s−1. Recent results have shown the involvement of Ca2+ in the triggering of the slow wave and the role of the H+ pump during the slow wave. Transient and fast biochemical responses. An entry of extraceilular Ca2+ into the cells and a transient increase in IP3 occur within seconds following the mechanical stimulus. At the same time, the membrane becomes more fluid, correlated with qualitative changes in phospholipids. The rapid increase in the concentration of peroxidated lipids may be correlated with ethylene biosynthesis which is stimulated after rubbing. Other parameters such as cytoplasmic pH, relative water content, hydric potential, membrane potential and modifications of K+, Mg2+-ATPase and Ca2+-ATPase activities, play a key role in the early responses induced by the traumatisms. Irreversible-biochemical responses. The mechanical stimulus performed on a Bryonia internode induces an acceleration of: i) enzymatic activities related to the lignification, ii) esterification of phenolic acids in the cell wall. Consequently the lignification process is accelerated. Storage of the information. After being received by the target cells the information can be stored during several days before being expressed. At the level of cotyledonary bud, the first message, previously stored, can be expressed or not by a second treatment. Bidens thus behaves as if it was able to “store” and to “retrieve” morphogenetic messages, using a sort of rudimentary memory. The nuclei of the bud cells of the pricked cotyledon show that these cells, initially in G2 phase, divide and then remain in the G1 phase. In Bryonia, calli derived from young stimulated internodes, keep thigmomorphogenetic characteristics during several weeks. In the last part of this paper the particularity of our plant model which permits a study of the transmission and storage of the message, is underlined. The links between the different steps induced by the stimulus are discussed. Special attention is devoted to second messengers and to the amplification of the message. (shrink)

The Dutch policy objective of a fully sustainable livestock sector without mutilations by 2023 is not compatible with the routine practice of tail docking to minimize the risk of tail biting. To examine farmer attitudes towards docking, a telephone survey was conducted among 487 conventional and 33 organic Dutch pig farmers. “Biting” (of tails, ears, or limbs) was identified by the farmers as a main welfare problem in pig farming. About half of the farmers reported to have no tail biting (...) problems in their own herd. When farmers did report problems, they most often reported figures between 1 and 5 % of the animals. High incidences of tail biting were anticipated when trying to keep undocked pigs. Enrichment materials used in the conventional sector included mainly chains (52–63 % of the farms) and hanging rubber or plastic balls (22–30 %). Straw, sawdust, or wood shavings was hardly provided in conventional pig farming (2–3 %), in contrast to organic farming (88–100 % of farms). Conventional pig farmers feel a curly tail is not very important for sustainable pig farming. They consider enrichment to be less effective and tail docking to be less stressful for them and their piglets than their organic colleagues do. Pig farmers identified climate as a main risk factor for tail biting as opposed to enrichment. The objective of reducing routine tail docking requires solutions for dealing with tail biting problems at the farm level. In this process, transfer of scientific knowledge about enrichment materials and other measures to prevent and cure tail biting is critical, as is a change in farmer attitudes and awareness of the moral issues involved. (shrink)

Is there ever any reason for a doctor to lie to a patient? In this paper, we critically review the literature on lying to patients and challenge the common notion that while lying is unacceptable, a related entity--'benevolent deception' is defensible. Further, we outline a rare circumstance when treating psychotic patients where lying to the patient is justified. This circumstance is illustrated by a clinical vignette.

Although it is commonly believed that the concept of brain death was developed to benefit organ transplants, it evolved independently. Transplantation owed its development to advances in surgery and immunosuppressive treatment; BD owed its origin to the development of intensive care. The first autotransplant was achieved in the early 1900s, when studies of increased intracranial pressure causing respiratory arrest with preserved heartbeat were reported. Between 1902 and 1950, the BD concept was supported by the discovery of EEG, Crile’s definition of (...) death, the use of EEG to demonstrate abolition of brain potentials after ischaemia, and Crafoord’s statement that death was due to cessation of blood flow. Transplantation saw the first xenotransplant in humans and the first unsuccessful kidney transplant from a cadaver. In the 1950s, circulatory arrest in coma was identified by angiography, and the death of the nervous system and coma dépassé were described. Murray performed the first successful kidney transplant. In the 1960s, the BD concept and organ transplants were instantly linked when the first kidney transplant using a brain-dead donor was performed; Schwab proposed to use EEG in BD; the Harvard Committee report and the Sydney Declaration appeared; the first successful kidney, lung and pancreas transplants using cadaveric donors were achieved; Barnard performed the first human heart transplant. This historical review demonstrates that the BD concept and organ transplantation arose separately and advanced in parallel, and only began to progress together in the late 1960s. Therefore, the BD concept did not evolve to benefit transplantation. (shrink)

BackgroundClinical Ethics Support (CES) services are offered to support healthcare professionals in dealing with ethically difficult situations. Evaluation of CES is important to understand if it is indeed a supportive service in order to inform and improve future implementation of CES. Yet, methods to measure outcomes of CES are scarce. In 2014, the European Moral Case Deliberation Outcomes Instrument (Euro-MCD) was developed to measure outcomes of Moral Case Deliberation (MCD). To further validate the instrument, we tested it in field studies (...) and revised it. This paper presents the Euro-MCD 2.0 and describes the revision process.MethodsThe revision process comprised an iterative dialogue among the authors as Euro-MCD-project team, including empirical findings from six Euro-MCD field-studies and input from European experts in CES and theory. Empirical findings contained perceptions and experiences of MCD outcomes among healthcare professionals who participated in MCDs in various settings in Norway, Sweden and the Netherlands. Theoretical viewpoints on CES, literature on goals of CES and MCD and ethics theory guided the interpretation of the empirical findings and final selection of MCD outcomes.ResultsThe Euro-MCD 2.0 Instrument includes three domains: Moral Competence, Moral Teamwork and Moral Action. Moral Competence consists of items about moral sensitivity, analytical skills and virtuous attitude. Moral Teamwork includes open dialogue and supportive relationships and Moral Action refers to moral decision-making and responsible care. During the revision process, we made decisions about adding and reformulating items as well as decreasing the number from 26 to 15 items. We also altered the sentence structure of items to assess the current status of outcomes (e.g. ‘now’) instead of an assumed improvement over time (e.g. ‘better’) and we omitted the question about perceived importance.ConclusionsThe Euro-MCD 2.0 is shorter, less complex and more strongly substantiated by an integration of empirical findings, theoretical reflections and dialogues with participants and experts. Use of the Euro-MCD 2.0 will facilitate evaluation of MCD and can thereby monitor and foster implementation and quality of MCD. The Euro-MCD 2.0 will strengthen future research on evaluation of outcomes of MCD. (shrink)

We present the idea of searching for X-rays as a signature of the mechanism inducing the spontaneous collapse of the wave function. Such a signal is predicted by the continuous spontaneous localization theories, which are solving the “measurement problem” by modifying the Schrödinger equation. We will show some encouraging preliminary results and discuss future plans and strategy.