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What we don’t talk about when we don’t talk about sex: results of a national survey of U.S. obstetricians/gynecologists

Janelle N Sobecki, Farr A Curlin, Kenneth A Rasinski, Stacy Tessler Lindau

Abstract
Introduction
Sexuality is a key aspect of women’s physical and psychological health. Research shows both patients and physicians face barriers to communication about sexuality. Given their expertise and training in addressing conditions of the female genital tract across the female life course, obstetrician/gynecologists (ob/gyns) are well-positioned among all physicians to address sexuality issues with female patients. New practice guidelines for management of female sexual dysfunction and the importance of female sexual behavior and function to virtually all aspects of ob/gyn care, and to women’s health more broadly, warrant up-to-date information regarding ob/gyns’ sexual history-taking routine.

Aims
To determine obstetrician/gynecologists’ practices of communication with patients about sexuality, and to examine the individual and practice-level correlates of such communication.

Methods
A population-based sample of 1154 practicing U.S. obstetrician/gynecologists (53% male; mean age 48 years) was surveyed regarding their practices of communication with patients about sex.

Main Outcome Measures
Self-reported frequency measures of ob/gyns’ communication practices with patients including whether or not ob/gyns discuss patients’ sexual activities, sexual orientation, satisfaction with sexual life, pleasure with sexual activity, and sexual problems or dysfunction, as well as whether or not one ever expresses disapproval of or disagreement with patients’ sexual practices. Multivariable analysis was used to correlate physicians’ personal and practice characteristics with these communication practices.

Results
Survey response rate was 65.6%. Sixty-three percent of ob/gyns reported routinely assessing patients’ sexual activities; 40% routinely asked about sexual problems. Fewer asked about sexual satisfaction (28.5%), sexual orientation/identity (27.7%), or pleasure with sexual activity (13.8%). A quarter of ob/gyns reported they had expressed disapproval of patients’ sexual practices. Ob/gyns practicing predominately gynecology were significantly more likely than other ob/gyns to routinely ask about each of the five outcomes investigated.

Conclusion
The majority of U.S. ob/gyns report routinely asking patients about their sexual activities, but most other areas of patients’ sexuality are not routinely discussed.

Sobecki JN, Curlin FA, Rasinski KA, Lindau ST. What we don’t talk about when we don’t talk about sex: results of a national survey of U.S. obstetricians/gynecologists. J Sex Med. 2012;9(1285-1294. Available from:

Withdrawal of Artificial Nutrition and Hydration for Patients in a Permanent Vegetative State: Changing Tack

Catherine Constable

Abstract
In the United States, the decision of whether to withdraw or continue to provide artificial nutrition and hydration (ANH) for patients in a permanent vegetative state (PVS) is placed largely in the hands of surrogate decision‐makers, such as spouses and immediate family members. This practice would seem to be consistent with a strong national emphasis on autonomy and patient‐centered healthcare. When there is ambiguity as to the patient’s advanced wishes, the presumption has been that decisions should weigh in favor of maintaining life, and therefore, that it is the withdrawal rather than the continuation of ANH that requires particular justification. I will argue that this default position should be reversed. Instead, I will argue that the burden of justification lies with those who would continue artificial nutrition and hydration (ANH), and in the absence of knowledge as to the patient’s advanced wishes, it is better to discontinue ANH. In particular, I will argue that among patients in PVS, there is not a compelling interest in being kept alive; that in general, we commit a worse violation of autonomy by continuing ANH when the patient’s wishes are unknown; and that more likely than not, the maintenance of ANH as a bridge to a theoretical future time of recovery goes against the best interests of the patient.

Constable, C. (2012), Withdrawal of Artificial Nutrition and Hydration for Patiens in a Permanent Vegetative State: Changing Tack. Bioethics, 26: 157–163

The Guatemala STD Inoculation Study as the Incentive to Change Modern Informed Consent Standards

Maria Constance Scheperle

Washington and Lee Journal of Civil Rights and Social Justice

Extract
As is now known, from 1946–48, the Venereal Disease Research Laboratory of the U.S. Public Health Service (PHS), the Pan American Sanitary Bureau (PASB), and the Guatemalan government spearheaded a study4 that intentionally infected and tested Guatemalan prisoners, asylum inmates, soldiers, and orphaned children.5 The research team, led by Dr. John C. Cutler, exposed Guatemalans to syphilis “through the use of infectious prostitutes or directly through [an] inoculum made from tissue of human and animal syphilitic gummas and chancres,”6 and then treated the Guatemalans with penicillin.7 Although the researchers acknowledged they could not use such methods in the United States,8 they experimented in secrecy and did not seek consent from human subjects.9 . . .

The Guatemala study was horrendous, and the legal standards and guidelines of its day failed to protect Guatemalans who were infected with syphilis. Similar studies are being conducted by U.S. researchers in developing nations around the world, whether through grants from the U.S. government or by private U.S. companies. These problems must be remedied, and the Research Participants Protection Modernization Act of 2011 provides the impetus for the U.S. to do so. As Amy Gutmann, Chair of the Presidential Commission for the Study of Bioethical Issues stated, “a civilization can be judged by the way that it treats its most vulnerable individuals. There is no position of vulnerability that is greater than to be the subject of a medical experiment.”.

Scheperle MC. The Guatemala STD Inoculation Study as the Incentive to Change Modern Informed Consent Standards. Washington Lee J Civil Rights Soc Just. 2012 Mar;18(2):425-471.

When Doctors Break the Rules: On the Ethics of Physician Noncompliance

Jeffrey Blustein

Cambridge Quarterly of Healthcare Ethics

Abstract
Avoiding complicity in injustice is not limited to engaging in acts of noncompliance on behalf of one’s patients. The injustices from which one’s patients suffer may be rooted in morally suspect norms to which the profession of medicine, or some influential part of it, has lent its support or that it has not opposed and from which it and its practitioners have benefited. There may also be injustices that the profession has condemned but that remain. In general, avoiding complicity in wrongdoing involves, as a base- line, understanding that the norms and practices responsible for it have contributed to making noncompliance an option that at least deserves serious moral consideration, if not endorsement. A physician may then decide to engage in some form of rule breaking in order to act on this understanding and express her refusal to be complicit.. . .Complicity threatens the moral and professional integrity of the physician, and noncompliance may be warranted in part because it is the only way that a physician can meet the threat.

Blustein J. When Doctors Break the Rules: On the Ethics of Physician Noncompliance. Camb Q Healthc Ethics. 2012;21(02):249-259.

Equality, Freedom & Religion

Roger Trigg. Equality, Freedom & Religion. Oxford: University Press; 2012 Jan 13, 224 pp. ISBN- 9780199576852.

Publisher’s Description
Is religious freedom being curtailed in pursuit of equality, and the outlawing of discrimination? Is enough effort made to accommodate those motivated by a religious conscience? All rights matter but at times the right to put religious beliefs into practice increasingly takes second place in the law of different countries to the pursuit of other social priorities. The right to freedom of belief and to manifest belief is written into all human rights charters. In the United States religious freedom is sometimes seen as ‘the first freedom’. Yet increasingly in many jurisdictions in Europe and North America, religious freedom can all too easily be ‘trumped’ by other rights.

Roger Trigg looks at the assumptions that lie behind the subordination of religious liberty to other social concerns, especially the pursuit of equality. He gives examples from different Western countries of a steady erosion of freedom of religion. The protection of freedom of worship is often seen as sufficient, and religious practices are separated from the beliefs which inspire them. So far from religion in general, and Christianity in particular, providing a foundation for our beliefs in human dignity and human rights, religion is all too often seen as threat and a source of conflict, to be controlled at all costs. The challenge is whether any freedom can preserved for long, if the basic human right to freedom of religious belief and practice is dismissed as of little account, with no attempt to provide any reasonable accommodation. Given the central role of religion in human life, unnecessary limitations on its expression are attacks on human freedom itself.

After-birth abortion: Why should the baby live?

Alberto Giubilini, Francesca Minerva

Abstract
Abortion is largely accepted even for reasons that do not have anything to do with the fetus’ health. By showing that (1) both fetuses and newborns do not have the same moral status as actual persons, (2) the fact that both are potential persons is morally irrelevant and (3) adoption is not always in the best interest of actual people, the authors argue that what we call ‘after-birth abortion’ (killing a newborn) should be permissible in all the cases where abortion is, including cases where the newborn is not disabled.

Giubilini A, Minerva F. After-birth abortion: Why should the baby live?. J Med Ethics. 2013;39(5):261-263.

Pediatricians’ experience with and response to parental vaccine safety concerns and vaccine refusals: a survey of Connecticut pediatricians

Susan Leib, Penny Liberatos, Karen Edwards

Abstract
Objectives. Physicians are seeing increasing numbers of parents who question the safety of vaccines or refuse to vaccinate their children. This study examined how frequently pediatricians in one New England state encounter parental vaccine safety concerns and vaccine refusals, how often physicians dismiss families from their practices for vaccine refusal, and how parental vaccine refusal impacts pediatricians personally.

Methods. The study consisted of a quantitative survey of primary care pediatri-cians in one New England state; 133 pediatricians completed the questionnaire. Variables examined included number of parental vaccine concerns and refusals seen by each physician, physicians’ response to parental vaccine concerns and refusals, the personal impact of parental vaccine safety refusals on pediatricians, and respondent estimates of socioeconomic characteristics of families seen in their practices.

Results. The majority of responding pediatricians reported an increase in parental vaccine safety concerns and refusals. More than 30% of responding pediatricians have dismissed families because of their refusal to immunize. Suburban physicians caring for wealthier, better educated families experience more vaccine concerns and/or refusals and are more likely to dismiss families for vaccine refusal. Vaccine refusals have a negative personal impact on one-third of physician respondents.

Conclusions. Pediatricians in Connecticut are reporting increased levels of parental vaccine safety concerns and refusals. Physicians who report more parental vaccine safety concerns and refusals and who care for wealthier, better educated families are more likely to dismiss families who refuse vaccines and to be negatively affected by parental vaccine refusals, which may adversely impact childhood vaccination rates.

Leib S, Liberatos P, Edwards K. Pediatricians’ experience with and response to parental vaccine safety concerns and vaccine refusals: a survey of Connecticut pediatricians. Public Health Rep. 2011 Jul-Aug;126 Suppl 2:13-23

Revalidation of the perceptions of conscience questionnaire (PCQ) and the stress of conscience questionnaire (SCQ)

Johan Ahlin, Eva Ericson-Lidman, Astrid Norberg, Gunilla Strandberg

Abstract
The Perceptions of Conscience Questionnaire (PCQ) and the Stress of Conscience Questionnaire (SCQ) have previously been developed and validated within the ‘Stress of Conscience Study’. The aim was to revalidate these two questionnaires, including two additional, theoretically and empirically significant items, on a sample of healthcare personnel working in direct contact with patients.The sample consisted of 503 healthcare personnel.To test variation and distribution among the answers, descriptive statistics, item analysis and principal component analysis (PCA) were used to examine the underlying factor structure of the questionnaires.Support for adding the new item to the PCQ was found.No support was found for adding the new item to the SCQ. Both questionnaires can be regarded as valid for Swedish settings but can be improved by rephrasing some of the PCQ items and by adding items about private life to the SCQ.

Ahlin J, Ericson-Lidman E, Norberg A, Strandberg G. Revalidation of the perceptions of conscience questionnaire (PCQ) and the stress of conscience questionnaire (SCQ). Nurs Ethics. 2012;19(2):220-232.

Conscience Rules: Implications for Care

Ryan Blum

Extract
On February 18, the Department of Health and Human Services issued a rule, “Regulation for the Enforcement of Federal Health Care Provider Conscience Protection Laws,” that limits health care providers’ power to shape their practice by personal conviction. The rule narrows possible conscientious objection significantly, protecting patients’ rights and in the process eliminating public reinforcement of the harmful idea that religion and medicine are always destined to diverge.

Blum R. Conscience Rules: Implications for Care. Hastings Cent Rep 2011;41(3):c3.

What makes killing wrong?

Walter Sinnott-Armstrong, Franklin G Miller

Abstract
What makes an act of killing morally wrong is not that the act causes loss of life or consciousness but rather that the act causes loss of all remaining abilities. This account implies that it is not even pro tanto morally wrong to kill patients who are universally and irreversibly disabled, because they have no abilities to lose. Applied to vital organ transplantation, this account undermines the dead donor rule and shows how current practices are compatible with morality.

Sinnott-Armstrong W, Miller FG. What makes killing wrong? J Medical Ethics 2013;39:3-7.