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Whole genome sequencing (WGS) is increasingly being used in clinical practice. As a result, various healthcare professionals now encounter ethical dilemmas that were formerly confined within the genetics clinic. In addition to autonomy and well-being of both patients and their family members, which need to be balanced carefully, a societal perspective is also vital to ensure the ethically sound introduction of whole genome sequencing into daily practice. Important choices to be made are: who is eligible for whole genome sequencing; how can informed consent be sensibly obtained, when dealing with such vast quantities of genomic information; which type of information should be offered to patients; should professionals actively search for pathogenic mutations. The rise of WGS has an impact on the moral responsibilities incumbent on healthcare professionals and necessitates a comprehensive societal debate on the advent of personalized medicine.

Objective: To explore general practitioners' (GP) experiences of dealing with requests for the renewal of weak opioid prescriptions for chronic non-cancer pain conditions., Design: Qualitative focus group interviews. Systematic text condensation analysis., Setting and Subjects: 15 GPs, 4 GP residents and 2 interns at two rural and two urban health centres in central Sweden., Main Outcome Measures: Strategies for handling the dilemma of prescribing weak opioids without seeing the patient., Results: After analysing four focus group interviews we found that requests for prescription renewals for weak opioids provoked adverse feelings in the GP regarding the patient, colleagues or the GP's inner self and were experienced as a dilemma. To deal with this, the GP could use passive as well as active strategies. Active strategies, like discussing the dilemma with colleagues and creating common routines regarding the renewal of weak opioids, may improve prescription habits and support physicians who want to do what is medically correct., Conclusion: Many GPs feel umcomfortable when prescribing weak opioids without seeing the patient. This qualitative study has identified strategic approaches to deal with that issue. Key points   Opioid prescription for chronic non-cancer pain is known to cause discomfort, feelings of guilt and conflicts for the prescribing doctor. From focus group interviews with GPs we found that to deal with this:   • Doctors can use active strategies, such as confronting the patient or creating common routines together with their colleagues, or…   • They can use passive coping strategies such as accepting the situation, handing over the responsibility to the patient or choosing not to see that there is a problem.   • Opportunities for doctors to discuss prescription routines may be the best way to influence prescription habits.

Aim: What are the reasons for institutionalising community-dwelling persons with dementia?, Method: A written survey of family caregivers and general practitioners was undertaken., Results: Within 2 years 47 of 351 people with dementia (13%) were institutionalised. The person with dementia was involved in the decision in only 1/3 of the cases. The 3 most common reasons were: ensuring the best possible care, high expenditure of care-giving time at home, deterioration of the health of the care-receiver., Conclusions: From the ethical point of view the exclusion of the persons with dementia from the decision-making with regard to institutionalisation has to be examined critically. The often given reason of ensuring the best possible care through institutionalisation could be counteracted by the improvement of community-based care., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Dealing with insistent patient demand for antibiotics is an all too common part of a General Practitioner's daily routine. This study explores the extent to which portable Immersive Virtual Reality technology can help us gain an accurate understanding of the factors that influence a doctor's response to the ethical challenge underlying such tenacious requests for antibiotics (given the threat posed by growing anti-bacterial resistance worldwide). It also considers the potential of such technology to train doctors to face such dilemmas., Experiment: Twelve experienced GPs and nine trainees were confronted with an increasingly angry demand by a woman to prescribe antibiotics to her mother in the face of inconclusive evidence that such antibiotic prescription is necessary. The daughter and mother were virtual characters displayed in immersive virtual reality. The specific purposes of the study were twofold: first, whether experienced GPs would be more resistant to patient demands than the trainees, and second, to investigate whether medical doctors would take the virtual situation seriously., Results: Eight out of the 9 trainees prescribed the antibiotics, whereas 7 out of the 12 GPs did so. On the basis of a Bayesian analysis, these results yield reasonable statistical evidence in favor of the notion that experienced GPs are more likely to withstand the pressure to prescribe antibiotics than trainee doctors, thus answering our first question positively. As for the second question, a post experience questionnaire assessing the participants' level of presence (together with participants' feedback and body language) suggested that overall participants did tend towards the illusion of being in the consultation room depicted in the virtual reality and that the virtual consultation taking place was really happening.

Background: Private practitioners (PPs) in high-burden countries often provide substandard tuberculosis (TB) treatment, leading to increased risk of drug resistance and continued transmission. TB case management among PPs in Indonesia has not been investigated in recent years, despite longstanding recognition of inadequate care and substantial investment in several initiatives. This study aimed to assess case management practices of private general practitioners (GPs) in eight major cities across Indonesia., Methods: A cross-sectional survey of private GPs was carried out simultaneously in eight cities by trained researchers between August and December 2011. We aimed for a sample size of 627 in total, and took a simple random sample of GPs from the validated local registers of GPs. Informed consent was obtained from participants prior to interview. Diagnostic and treatment practices were evaluated based on compliance with national guidelines. Descriptive statistics are presented., Results: Of 608 eligible GPs invited to participate during the study period, 547 (89.9%) consented and completed the interview. A low proportion of GPs (24.6-74.3%) had heard of the International Standards for TB care (ISTC) and only 41.2-68.9% of these GPs had participated in ISTC training. As few as 47.3% (90% CI: 37.6-57.0%) of GPs reported having seen presumptive TB. The median number of cases of presumptive TB seen per month was low (0-5). The proportion of GPs who utilized smear microscopy for diagnosing presumptive adult TB ranged from 62.3 to 84.6%. In all cities, a substantial proportion of GPs (12.0-45.5%) prescribed second-line anti-TB drugs for treating new adult TB cases. In nearly all cities, less than half of GPs appointed a treatment observer (13.8-52.0%)., Conclusions: The pattern of TB case management practices among private GPs in Indonesia is still not in line with the guidelines, despite longstanding awareness of the issue and considerable trialing of various interventions.

Questions Under Study: Although the ethical and health implications of neuroenhancement have been intensely discussed over the past years, little is known about the experiences and attitudes of physicians confronted with requests for neuroenhancing substances. The aim of this study was to explore general practitioners' and psychiatrists' familiarity with such requests and their willingness to prescribe these products., Method: A nation-wide cross-sectional survey among general practitioners and psychiatrists in Switzerland was conducted. A questionnaire was developed, pre-tested and sent out to a pre-defined sample of 1,600 Swiss practising physicians in the fields of psychiatry and general practice/internal medicine in the German-speaking and French-speaking part of Switzerland., Results: A total of 393 questionnaires were returned (response rate: 24.7%). 80.2% of study participants were encountered requests for neuroenhancing products in their own practice, mostly not exceeding 1-2 times a year. A total of 41.1% were undecided when asked if they categorically against neuroenhancement, 49% would decide on a case-by-case basis, and 9.6% would decide according to patients' wishes., Conclusions: Swiss psychiatrists and general practitioners are confronted with requests for neuroenhancement, albeit not very frequently. Most participants embrace a pragmatic position towards neuroenhancement, although there is also a considerable degree of uncertainty about the appropriateness of a categorical refusal. A minority would follow a consumer model that leaves the decision about the use of neuroenhancers to the client, even though this conflicts with legal requirements regarding drug prescriptions.

Controversial and ethically tenuous, the use of placebos is central to medicine but even more pivotal to psychosocial therapies. Scholars, researchers, and practitioners largely disagree about the conceptualization of placebos. While different professionals often confound the meanings of placebo effects with placebo responses, physicians continue to prescribe placebos as part of clinical practice. Our study aims to review attitudes and beliefs concerning placebos outside of clinical research. Herein we compare patterns of placebo use reported by academic psychiatrists with those reported by physicians from different specialties across Canadian medical schools. Using a web-based tool, we circulated an online survey to all 17 Canadian medical schools, with a special emphasis on psychiatry departments therein and in university-affiliated teaching hospitals. A variation on earlier efforts, our 5-minute, 21-question survey was anonymous. Among the 606 respondents who completed our online survey, 257 were psychiatrists. Our analysis revealed that psychiatrists prescribed significantly more subtherapeutic doses of medication than physicians in other specialties, although about 20% of both psychiatrists and nonpsychiatrists prescribed placebos regularly as part of routine clinical practice. However, compared with 6% of nonpsychiatrists, only 2% of psychiatrists deemed placebos of no clinical benefit. In addition, more than 60% of psychiatrists either agreed or strongly agreed that placebos had therapeutic effects relative to fewer than 45% of other practitioners. Findings from this pan-Canadian survey suggest that, compared with other physicians, psychiatrists seem to better value the influence placebos wield on the mind and body and maintain more favourable beliefs and attitudes toward placebo phenomena.