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I shall now consider the potential implications of a positive result 16mg depo-medrol overnight delivery, the nature of the relationship between the health professional and the pregnant woman purchase 16 mg depo-medrol visa, and the process of consent buy 16 mg depo-medrol amex, as these are all relevant to a discussion about the ethics of anonymized and named testing. The implications of a positive result A pregnant woman is likely to experience considerable distress on discovery of her positive status (Manuel, 1999), particularly as she may feel more vulnerable and dependent on others, and she has the added responsibility of motherhood ahead of her. Once born, however, the interests of the child are paramount, and parental views may be overridden if they are seen to conXict with the child’s welfare. Babies can still gain protection from infection if given antiviral treatment within 48 hours of birth, even if the mother has refused to take medication or have a Caesarean section (Wade et al. It is beyond the scope of this discussion to consider the poignant dilemma for parents of whether or not to disclose to their child his or her incurable infection and uncertain life expectancy, or to explore the burden of imposing life-long unpleasant treatment on a child, and of protect- ing him or her from stigma. It is evident from the case above, however, that women may Wnd that breast-feeding causes disapprobation, and may even result in their infants being considered ‘at risk’. Abstention from breast-feeding creates particular diYculties in countries and cultures where breast-feeding is the norm, and bottle-feeding stigmatizes a woman (Graham and Newell, 1999). The relationship between the health professional and the patient As I have discussed elsewhere (de Zulueta, 2000a), the relationship between a health professional and a patient can be characterized as a Wduciary one. The health professional is therefore entrusted to put the patient’s interests Wrst, and to hold certain things (such as conWdential information) ‘in trust’. As Brazier succinctly expresses this: ‘It is trite to describe the health profes- sional’s relationship with his or her patient as a relationship of trust, yet the description encapsulates the very heart of the relationship’ (Brazier and Lobjoit, 1999: p. The health professional has a duty to promote the well-being of both the mother and the unborn child, but should only provide care that the mother agrees to. Failure to seek the patient’s consent is not only a moral failure, but, in English law, also leaves the doctor liable to the tort or crime of battery or to the tort of negligence. The information required is such that the patient understands in broad terms the nature and purpose of the procedure, and the principal risks, beneWts and alternatives (Chatterton v Gerson, 1981). Consent is a process, not an event, and involves a continuing dialogue between the health care professional and the patient, such that there is genuine shared decision-making. I submit that in the case of anonymized testing, and in the case of ‘routine’ voluntary named testing, consent is often vitiated by a lack of understanding and information, and sometimes by coercion. This may be justiWed in countries where the resources are not available to oVer counselling or treatment, and where the data may be used to galvanize the developed world into providing aid. These Wgures, it is argued, can then be used to provide the justiWcation for allocating more resources to the treatment and prevention of the disease, particularly in areas of high prevalence. But I would counter-argue that it is unprofessional and unethical to encourage individuals to relinquish beneWts that may aVect third parties (human fetuses), even if these are not ‘legal persons’. Finally, it could be argued that if an informed mother agrees to anony- mized testing, she does not intend to deprive the fetus of beneWt, as she does not know if she harbours the virus. This argument is also used to justify the health professional’s behaviour – no harm is intended, and there is no responsibility to act upon the result since it is unobtainable. A woman attending an antenatal clinic carries the reasonable expecta- tion that all tests and procedures are done either directly to beneWt her or her unborn child (de Zulueta, 2000a). The case for abuse of trust is even stronger than with anonymized testing of pregnant women, as the mothers are even more likely to assume that all tests are for the baby’s beneWt. Since the baby relies entirely on others to protect his interests, it is arguably even more unethical to use the baby ‘merely as a means, rather than as an end in himself’, to paraphrase Kant. In order to make an informed choice, the woman needs to understand the nature of the test itself, as well as the advantages and disadvantages of not receiving the result should it be positive. They cite a case when a doctor was found in breach of duty for failing to inform a woman of the potential consequences of not agreeing to a cervical smear. In addition, the leaXet issued by the Department of Health, in circulation after 1994, does not refer to treatments available for reducing vertical transmission. In any case, the notion of passive consent, that is to say that consent is implied unless there is a verbal refusal, is ethically unsound and ‘a concept quite alien in English law’ (Brazier and Lobjoit, 1999: p. In clinics that pro- vide universal testing (see later), the women should have received the relevant information from a pre-test discussion with the midwife, and the 70 P. In one study only Wve per cent fully understood the nature of the testing, and a signiWcant proportion believed that they would be informed should the result be positive (Chrystie et al. The principle of autonomy is frequently infringed by the process of anonymized testing, and, as Brazier says, ‘Consent truly is a myth’ (Brazier and Lobjoit, 1999: p. The ethics of named testing The Department of Health’s Unlinked Anonymous Surveys Steering Group in 1989 rejected mass voluntary testing as an alternative to anonymized testing. As argued above, the beneWts of named testing, and the arguments in favour of truth-telling are further strengthened, particularly as third parties are placed at risk by non-disclosure. The majority of industrialized countries adopted a universal testing policy (whereby all women were oVered the test), and developed their own guide- lines.

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But we must also be revolutionary because the re­ sources that will be needed to try new approaches are cur­ rently harnessed to a sophisticated 16mg depo-medrol overnight delivery, professionalized medical care system which generic 16mg depo-medrol with visa, in the interests of aiding the few depo-medrol 16 mg fast delivery, sacrifices the health of the many. W ithin the next few years, Congress will enact a program o f national health insurance. This legislation will underwrite the costs of care for all citizens of the United States. But if it can be shown, for example, that spending a dollar on educa­ The Arguments 3 tion would improve health m ore than spending the same dollar on health services, or if it could be dem onstrated that diet and nutrition are far m ore im portant to health than any am ount o f curative care, the need for a national health insurance program becomes doubtful. The issues should be o f vital interest to those interested in fiscal austerity and lean governm ent, as well as to those who feel that health is o f the greatest national im portance, irrespec­ tive of cost. Should we indenture our health in the future to the existing medical care system when better health might be ensured through other means? T he answer should be no; but it is virtually certain that Congress will do so, and with the support of the vast majority of the people. It calls for the dissolution of the largest and most expensive social service system in the world—the medical care system in the United States. The “radical” critique centers first on the exploitation of the hapless consum er by the rapacious provider and, second, on the failure of the “system” to extend services to everyone, in spite o f the alleged exploitation. This analysis is accurate as far as it goes, but it fails to engage the pivotal issue—what does medicine have to do with health? T he radical solution—the provision o f care to everyone— may simply result in m ore care for those who may not need it. But if it is health we care about, and not medical care, we m ust look for im provem ents in the life setting of the unhealthy, not simply the provision of services designed to cure them once they are sick. If this can be done, then a leaner and tougher approach to health can be created out of the remains of the current delivery system. T he new approach will build on 4 Introduction those things that generate health; unlike present-day medicine, it will not rely on profound interventions when health has been lost. T he United States is about to enter into a “contract” with the exisdng medical care deliv­ ery system by legislating its legitimacy through a national health insurance program. I begin with evidence on the relative impact of personal m edi­ cal care and a set of socioenvironmental factors. It is here, in C hapter 2, that m uch of the research and literature on the “effectiveness” of medical care is compiled. T hen I turn to a history o f the “crisis” in health care, together with a discus­ sion o f its evolutionary features, to show where and how it is evolving. Next I turn to some “social futures” for the United States and their implications for health. This is done dialec- tically, by contrasting the evolution of medicine with a pro­ jection of the future, to dem onstrate the divergence between the medical care system and the larger society of which it is a part. T he end of medicine is coming both because of inter­ nal contradictions within the present system and because the system does not correspond with an em erging Zeitgeist. In C hapter 6, I attem pt to state what health is, having spent five chap­ ters spelling out what it is not. In C hapter 7, through a brief historical analysis o f the eras of medicine, I propose some o f the elements of a new paradigm for health. In this last chapter I also resurrect the question of national health in­ surance, because it is on this question that the public debate about health care will turn. If a comprehensive program of national health insurance is prom ulgated in the next few The Arguments 5 years, as is almost certain, the structure, prerogatives, and style of practice of the existing medical care system will be frozen for decades. If the outcome is simply m ore medical care, our health will be worse and our well-being as a popu­ lation will be in jeopardy. Finally, in an epilogue I draw the broad outlines o f a new medicine, which must be calibrated with the future and specifically with the health care needs o f the future. Although most of the points are docum ented, the ultimate test is their theoretical strength. T hree characteristics of medical practice are particularly perplexing to the uninitiated. First, determ inations of the quality of care are made with­ out reference to the actual outcomes of care to the patient. To use a homely example, most of us judge a restaurant on the basis of the taste and quality o f the food. Seldom do we inquire as to the chefs lineage or education, or visit the kitchen to inspect the ovens and utensils. The quality of means and the results of health care are m atters of different im portance and m agnitude, but the analogy fits. Unlike the quality of food, the regulatory measures traditionally em­ ployed to control the quality of medical care have focused on who renders it and how, m ore often than on what the results have been. T here is one notable exception, although Florence Night­ ingale should get similar kudos. Codm an, a surgeon at Massachusetts General Hospital, sought to orient assessment o f the quality of medical care from structural or input evaluation—who did it—to process 6 The Impact of Medicine 7 and end-result evaluation—how and why.

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Aminophylline most likely inhibits the local and systemic effects of adenosine by blocking the adenosine receptor sites discount 16 mg depo-medrol otc. Reinjection and 24H image protocols have been developed to increase the detection of viable myocardium order depo-medrol 16 mg fast delivery. About 30-50% of fixed defects on 4H redistribution images show reperfusion on reinjection or 24H images discount depo-medrol 16mg with mastercard. Detection of coronary artery disease and identification of injured but viable myocardium Assessment of myocardium viability can be done using various single photon and positron labeled imaging agents. The advantages of a single acquisition include patient convenience, shorter length of image acquisition, and perfect registration of the images. Determination of extent of myocardial viability in patients with coronary artery disease. See Patient Preparation for Cardiac Stress Exam under Cardiac Stress Protocols (Section 10. Reconstruct the images, reorient and display images along short axis, vertical long axis and horizontal long axis of the heart. See Patient Preparation for Cardiac Stress Exam under Cardiac Stress Protocols (Section 10. See Exercise, Adenosine, and Dobutamine Stress Test under Cardiac Stress Protocols (Section 10. Reconstruct the images, reorient and display images along short axis, vertical long axis and horizontal long axis of the heart. Adult Dose: Resting scan: 8-10 mCi (dependent on weight) Stress scan: 25-30 mCi (dependent on weight) 3. See Patient Preparation for Cardiac Stress Exam and Dobutamine Stress Test under Cardiac Stress Protocols (Section 10. For patients with a high likelihood of major interference from attenuation artifact (> 280- 300#) due to their body habitus, a two day protocol using 25-30 mCi on each day should be used. See Patient Preparation for Cardiac Stress Exam and Exercise, Adenosine, and Dobutamine Stress Test under Cardiac Stress Protocols (Section 10. For logistical reasons, a low-dose stress, high-dose rest procedure can be used as deemed appropriate by the physicians. Reconstruct the images, reorient and display images along short axis, vertical long axis and horizontal long axis of the heart. The 24-hour Tl-201 image in dual isotope myocardial perfusion scintigraphy: clinical utility and prognostic significance. See Patient Preparation for Cardiac Stress Exam and Exercise, Adenosine, and Dobutamine Stress Test under Cardiac Stress Protocols (Section 10. This procedure is not appropriate for patients with a high likelihood of major interference from attenuation artifact (> 280-300#) due to their body habitus; a two day protocol using 99m 25-30 mCi of a Tc pharmaceutical on each day should be used. See Patient Preparation for Cardiac Stress Exam and Exercise, Adenosine, and Dobutamine Stress Test under Cardiac Stress Protocols (Section 10. Reconstruct the images, reorient and display images along short axis, vertical long axis and horizontal long axis of the heart. A rest only (“pain”) study is available 8 am to 10 pm weekdays using Tc if the patient can be injected during chest pain or within 30-40 minutes of pain relief;. If thallium is unavailable late in the day, a low dose stress/high dose rest Tc study is appropriate Weekends and Holidays 1. That physician will be a nuclear medicine physician-in-training (fellow/resident), a nuclear medicine attending, or a cardiology fellow who has been trained in nuclear cardiology (this is a negotiated settlement depending on which fellows are readily available). These patients will need to be assessed by the nuclear cardiology physician-in-training in consultation with the referring physician as to appropriateness before ordering a dose, and that physician is responsible for communicating with the on-call technologist and the physician who will be performing the stress procedure. Myocardial perfusion imaging for evaluation and triage of patients with suspected acute cardiac ischemia: a randomized controlled trial. Impact of acute chest pain Tc-99m sestamibi myocardial perfusion imaging on clinical management. See Patient Preparation for Cardiac Stress Exam and Exercise Stress Test under Cardiac Stress Protocols (Section 10. For patients with a high likelihood of major interference from attenuation artifact (> 280- 300#) due to their body habitus, a protocol using 30 mCi should be used. Reconstruct the images, reorient and display images along short axis, vertical long axis and horizontal long axis of the heart. Equipment: Dual head camera with 511 keV ultra high energy collimators Radiopharmaceutical Administration: 99m 99m 1. Time interval between administration and scanning: 60 minutes Patient Preparation: 1. See Patient Preparation for Cardiac Stress Exam under Cardiac Stress Protocols (Section 10. The computer will normalize each raw data group one at a time, correcting for decay, uniformity, and center of rotation.

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