The right not to hear: the ethics of parental refusal of hearing rehabilitation

Sensitivity to Deaf Culture Among Otolaryngology and Audiology Trainees

OBJECTIVE

The Deaf community is an ethnolinguistic minority group. Low sensitivity to Deaf culture contributes to health disparities among Deaf patients. This study determines the level of sensitivity to Deaf culture among otolaryngology-head and neck surgery (OHNS) and audiology trainees.

METHODS

Cross-sectional survey study of OHNS and audiology trainees from 10 large US institutions. Trainees were queried on their exposure to and comfort with Deaf patients and their education on, attitude toward, and awareness and knowledge of Deaf culture. Sensitivity to Deaf culture was operationalized as awareness and knowledge of Deaf culture. These were assessed using a 35-item instrument that was previously developed using a d/Deaf community-based participatory approach to research. We used T-tests to compare the sample to previous samples of medical students with training in Deaf culture (MS-TDCs) and general practitioners (GPs).

RESULTS

There were 91 completed surveys (response rate 44.5%). Almost all were aware of Deaf culture (97.8%). The mean knowledge score was 55.0% (standard deviation (SD) 13.4%), which was significantly higher than that for GPs at 43.0% (SD 15.0%) (95% confidence interval 8.1%, 15.8%, P < .0001) but significantly lower than that for MS-TDCs at 69.0% (SD 13.0%)(CI -20.3%, -7.6%, P < .0001). Knowledge scores were comparable for OHNS and audiology trainees (P = .09).

CONCLUSION

This sample of OHNS and audiology trainees was more sensitive to Deaf culture than GPs but less sensitive than MS-TDCs. Developing specialty-specific education may be warranted.

LEVEL OF EVIDENCE

4.

Ethical implications of visual neuroprostheses-a systematic review

Objective. The aim of this review was to systematically identify the ethical implications of visual neuroprostheses.Approach. A systematic search was performed in both PubMed and Embase using a search string that combined synonyms for visual neuroprostheses, brain-computer interfaces (BCIs), cochlear implants (CIs), and ethics. We chose to include literature on BCIs and CIs, because of their ethically relavant similarities and functional parallels with visual neuroprostheses.Main results. We included 84 articles in total. Six focused specifically on visual prostheses. The other articles focused more broadly on neurotechnologies, on BCIs or CIs. We identified 169 ethical implications that have been categorized under seven main themes: (a) benefits for health and well-being; (b) harm and risk; (c) autonomy; (d) societal effects; (e) clinical research; (f) regulation and governance; and (g) involvement of experts, patients and the public.Significance. The development and clinical use of visual neuroprostheses is accompanied by ethical issues that should be considered early in the technological development process. Though there is ample literature on the ethical implications of other types of neuroprostheses, such as motor neuroprostheses and CIs, there is a significant gap in the literature regarding the ethical implications of visual neuroprostheses. Our findings can serve as a starting point for further research and normative analysis.

Audiologist’s Perspective in Auditory Rehabilitation: Implications for Ethical Conduct and Decision-Making in Portugal

Ethical standards in audiology have been continuously improved and discussed, leading to the elaboration of specific regulatory guidelines for the profession. However, in the field of auditory rehabilitation, audiologists are still faced with circumstances that question their ethical principles, usually associated with the support of the hearing aids industry. The study explores the decision-making process and ethical concerns in auditory rehabilitation as they relate to the practice of audiology in Portugal. An online questionnaire constructed by the authors was used and sent to the email addresses of a list of audiologists, registered with the Portuguese Association of Audiologists. The questionnaire was answered by 93 audiologists with clinical experience in auditory rehabilitation for more than one year. The collected data demonstrated that audiometric results and clinical experience are the most important factors for decision-making in auditory rehabilitation practice. Moreover, incentives from the employers or manufacturers were identified as the main cause of ethical dilemmas. This study highlights the ethical concerns regarding the clinical practice of auditory rehabilitation in Portugal, revealing that the decision-making process is complex and, specifically in this field, the current practice may not be adequate for effective compliance with professional ethical standards.

Patient, parental and multi-disciplinary team rationale for non-implantation following the paediatric cochlear implantation assessment

OBJECTIVES

To assess paediatric patients referred to the cochlear implant team, who despite undergoing the assessment, did not receive cochlear implantation. To identify the underlying reasons for this.

METHODS

A retrospective case-note review of patients was assessed from June 2014 to June 2019 at two separate London teaching hospitals with paediatric cochlear implantation programmes.

RESULTS

A total of 921 paediatric patients were assessed during the study period across both institutions. And, 196 (21%) did not proceed with the surgery. The decision not to undergo surgery was primarily parental/patient-directed in 114 (61%) and cochlear implant team-directed in 74 (39%). In total, eight (4%) patients exited the programme without a documented reason.

DISCUSSION

A myriad of factors influenced the decision-making process for clinicians, patients and parents. The most cited parental/patient rationale against implantation was the wish to continue current means of communication 40 (35%), followed by concern regarding the risks of surgery 18 (15.8%) and the wish to allow the patient to make future decisions independently in view of the future technology 7 (6.1%). Cochlear implant team-directed decisions were largely due to being outside of the NICE criteria 27 (36.5%) or the risks of general anaesthesia 19 (25.7%) in addition to communication concerns 11 (14.9%).

CONCLUSION

Decision-making in cochlear implantation should not be underestimated. Extensive discussion and exploration of options with the multi-disciplinary team can aid decision-making, but the timescale and appreciation of the consequences of the decision inevitably lead to pressure. Exploration of reasons for non-implantation emphasises the importance of a multi-professional approach to manage these patients.

Clinical Excellence in Otolaryngology-Head and Neck Surgery: Examples from the Published Literature

OBJECTIVE/HYPOTHESIS

To apply the domains of clinical excellence, as published by the Miller-Coulson Academy of Clinical Excellence, to the field of otolaryngology-head and neck surgery (OHNS) as a framework for evaluating and improving clinical excellence.

METHODS

A search of PubMed, Scopus, the Cochrane Library, and the National Institute for Health and Care Excellence (NICE) databases was performed and 229 publications were reviewed.

RESULTS

Case reports and other articles were selected that exemplify each of the distinct domains of clinical excellence within our specialty.

CONCLUSIONS

The Miller-Coulson Academy's domains of clinical excellence are relevant to OHNS and can provide a framework for fostering clinical excellence in otolaryngologists. The many examples of excellent care by otolaryngologists found in the published literature can inspire otolaryngologists to provide outstanding care to all patients consistently and to advance our specialty.

LEVEL OF EVIDENCE

N/A Laryngoscope, 131:E2153-E2158, 2021.

The moral case for sign language education

Here, a moral case is presented as to why sign languages such as Auslan should be made compulsory in general school curricula. Firstly, there are significant benefits that accrue to individuals from learning sign language. Secondly, sign language education is a matter of justice; the normalisation of sign language education and use would particularly benefit marginalised groups, such as those living with a communication disability. Finally, the integration of sign languages into the curricula would enable the flourishing of Deaf culture and go some way to resolving the tensions that have arisen from the promotion of oralist education facilitated by technologies such as cochlear implants. There are important reasons to further pursue policy proposals regarding the prioritisation of sign language in school curricula.

The Ethics of Cranial Nerve Implants

This overview of ethical and social issues pertaining to cranial nerve implants covers informed consent; risk-benefit assessments; security against unauthorized reprogramming or privacy intrusion; explantation; psychological side effects; equity and social distribution, cultural effects, for instance, on the deaf subculture; enhancement; and research ethics.

Medical neglect at a tertiary paediatric hospital

Medical neglect is under-researched and the extent of the problem in Australia is unknown. We conducted a review of the referrals for medical neglect to the Child Protection Unit (CPU) at a tertiary children's hospital in Sydney over a 5 years period, from 2011 to 2016, to determine what medical conditions are being referred, the reason for the medical neglect concern and whether cases are managed in line with American Academy of Pediatrics (AAP) guideline on medical neglect. 61 cases of medical neglect were identified, constituting 4.1% of all referrals to the Child Protection Unit for physical abuse and neglect. There was a wide variety of medical conditions. Most were chronic medical conditions (87%). The top two medical conditions were chronic and complex multi-system disorders (37.7%) and endocrine disorders (18%). The majority of medical neglect were related to concerns that the caregivers were unwilling to follow medical advice (45.9%) or unable to provide necessary medical care (26.2%). In line with the AAP guideline on medical neglect, all cases were managed by addressing communication difficulties (100%) and resource issues were addressed in 80% of cases. A report to statutory child protection agencies was made in 50% of cases. Directly observed therapy and medical contracts were used in 30% and 26% of cases. We conclude that children with chronic medical conditions may be at risk of medical neglect. Communication difficulties were a factor in all cases. Statutory agency intervention is often required.

Parental stress in raising Mandarin-speaking children with cochlear implants

OBJECTIVES/HYPOTHESIS

To investigate the characteristics of parental stress in the child, parent, and total domains in families of Mandarin-speaking children with cochlear implants at four different time periods in the implantation process. Previous studies have shown that parental stress lessens after cochlear implantation surgery.

STUDY DESIGN

Cross-sectional case series.

METHODS

Self-reported questionnaires based on Abidin's Parenting Stress Index (Taiwanese edition) were filled out by 113 mothers of children with cochlear implants. Factors related to parental stress were analyzed. In addition, we calculated the percentage of families experiencing high levels of stress (percentile ≥ 90) and compared the differences in stress level between each time period (preoperatively, postoperative time < 2 years, postoperative time between 2 and 5 years, and postoperative time >5 years).

RESULTS

Parent socioeconomic status, patient sex, and patient age were significantly related to the total parental stress. In the study of families experiencing high-stress between each time period, we found that parents had the highest level of parenting stress during the period of 0 to 2 years postoperatively in the total (odds ratio, 1.89) and child domain (odds ratio, 4.23). The contrary result was found in the parent domain, of which the highest odds ratio was found in the preoperative period.

CONCLUSIONS

Although parental stress in the parent domain lessened after the cochlear implantation surgery, parents experienced the highest level of total parental stress during the period of 0 to 2 years postoperatively. The degree of total parenting stress did not lessen after the cochlear implantation surgery.

LEVEL OF EVIDENCE

4.

“Obligatory Technologies”

The ideas of technological determinism and the autonomy of technology are long-standing and widespread. This article explores why the use of certain technologies is perceived to be obligatory, thus fueling the fatalism of technological determinism and undermining our sense of freedom vis-à-vis the use of technologies. Three main mechanisms that might explain “obligatory technologies” (technologies that must be adopted) are explored. First, competition between individuals or groups drives the adoption of technologies that enhance or extend human capacities. Second, individuals and groups may become dependent on technologies. Third, technologies induce changes in social norms and values that may come to be enforced through various social mechanisms, including the law. The widespread ideology of the beneficence and inevitability of technological progress in our culture helps this process along.

Medullary thyroid carcinoma: ethical issues for the surgeon

Medullary thyroid cancer is a disease with an established genetic inheritance pattern for which evidence-based guidelines recommend genetic testing and subsequent management of affected patients and their family members. The perceived stigma of genetic testing, coupled with issues involving confidentiality and disclosure, create potential conflict and confusion. In some cases, there is a need for genetic testing and prophylactic surgery in children, augmenting the need for a judicious approach that balances respect for individual autonomy and parental rights with the best interest of the child. We provide an overview of the ethical issues facing surgeons caring for patients with familial medullary thyroid carcinoma, and recommend interventions and resources to assist in decision making in these difficult situations.