Feminist ethics and menopause: autonomy and decision-making in primary medical care

Emerging ethical issues in reproductive medicine: are bioethics educators ready?

Advocates for the professionalization of clinical bioethics argue that bioethics professionals play an important role in contemporary medicine and patient care, especially when addressing complex ethical questions that arise in the delivery of reproductive medicine. For bioethics consultants to serve effectively, they need adequate training in the medical and ethical issues that patients and clinicians will face, and they need skills to facilitate effective dialog among all parties. Because clinical ethics consultation is a "high-stakes endeavor" that can acutely affect patient care, efforts are under way to ensure that bioethics consultants have the competence to provide such guidance. Yet to date, no studies have examined whether the training of bioethics consultants meets the needs of health care professionals who are on the front lines of such issues. In fact, limited information is available on the reproductive health issues that bioethics training programs address or the degree to which these programs meet the needs of patients confronting reproductive health decisions and their clinicians. It is therefore important to answer this key question: What are the primary ethical issues encountered in reproductive medicine that currently affect patient care? Equally important, are bioethics training programs prepared to address those issues? To begin to answer these questions, we conducted parallel surveys of directors of graduate bioethics training programs and obstetrician-gynecologists. The goal of this project is to lay the groundwork to establish a working partnership between bioethics educators and reproductive medicine practitioners to address the often troubling and frequently complex ethical issues in reproductive medicine.

Menopause: A complex and controversial journey

Menopause is defined as permanent cessation of menstrual periods, determined retrospectively after a woman has experienced 12 months of amenorrhea without any other obvious cause. Over the years, the discourse surrounding the Climacteric was mainly elicited as a "disease of the castrates", as opposed to the feminist views. There has been a large feminist contribution to both the debate of contraception and menopause in the last few years. Over the years, menopause has been treated in a uniform fashion, as a disease, excluding the different circumstances and lived experiences that patients go through during this sensitive period. Every primary care provider should be familiar with the menopausal process and be able to provide adequate care for these women, respecting patient's autonomy and decision making. A brief historical of menopause and hormone replacement therapy (HRT) will be reviewed in this paper. We will also discuss the different views of the menopausal discourse as well as the benefits and risks, compliance rates and reasons for discontinuation of HRT.

Data Safe Havens in health research and healthcare

Motivation: The data that put the ‘evidence’ into ‘evidence-based medicine’ are central to developments in public health, primary and hospital care. A fundamental challenge is to site such data in repositories that can easily be accessed under appropriate technical and governance controls which are effectively audited and are viewed as trustworthy by diverse stakeholders. This demands socio-technical solutions that may easily become enmeshed in protracted debate and controversy as they encounter the norms, values, expectations and concerns of diverse stakeholders. In this context, the development of what are called ‘Data Safe Havens’ has been crucial. Unfortunately, the origins and evolution of the term have led to a range of different definitions being assumed by different groups. There is, however, an intuitively meaningful interpretation that is often assumed by those who have not previously encountered the term: a repository in which useful but potentially sensitive data may be kept securely under governance and informatics systems that are fit-for-purpose and appropriately tailored to the nature of the data being maintained, and may be accessed and utilized by legitimate users undertaking work and research contributing to biomedicine, health and/or to ongoing development of healthcare systems.

Results: This review explores a fundamental question: ‘what are the specific criteria that ought reasonably to be met by a data repository if it is to be seen as consistent with this interpretation and viewed as worthy of being accorded the status of ‘Data Safe Haven’ by key stakeholders’? We propose 12 such criteria.

Contact:paul.burton@bristol.ac.uk

Pastoral power and gynaecological examinations: a Foucauldian critique of clinician accounts of patient-centred consent

Invasive non-sedated clinical procedures such as gynaecological examinations are normalised; however, there is limited research highlighting the relational and technical skills required for clinicians to ensure patients' continued consent. A considerable body of research emphasises that women dislike examinations, leading to their non-compliance or a delayed follow up for gynaecological and sexual health problems. However, medical research focuses on 'problem' women; the role of clinicians receives limited appraisal. This article draws on interviews with sexual health clinicians in New Zealand, from metropolitan and provincial locations. The gynaecological care of women in New Zealand attained international notoriety with the 1988 publication of Judge Cartwright's inquiry into ethical shortcomings in cervical cancer research at the National Women's Hospital. Judge Cartwright's recommendations included patient-centred care in order to ensure informed consent had been received for clinical procedures and research participation. This article's critical analysis is that, although clinicians' language draws on humanistic notions of patient-centredness, Foucault's notion of secularised pastoral power enables a more nuanced appreciation of the ethical work undertaken by clinicians when carrying out speculum examinations. The analysis highlights both the web of power relations present during examination practices and the strategies clinicians use to negotiate women's continued consent; which is significant because consent is usually conceptualised as an event, rather than an unfolding, unstable process.

Situationally-sensitive knowledge translation and relational decision making in hyperacute stroke: a qualitative study

Stroke is a leading cause of disability. Early treatment of acute ischaemic stroke with rtPA reduces the risk of longer term dependency but carries an increased risk of causing immediate bleeding complications. To understand the challenges of knowledge translation and decision making about treatment with rtPA in hyperacute stroke and hence to inform development of appropriate decision support we interviewed patients, their family and health professionals. The emergency setting and the symptomatic effects of hyper-acute stroke shaped the form, content and manner of knowledge translation to support decision making. Decision making about rtPA in hyperacute stroke presented three conundrums for patients, family and clinicians. 1) How to allow time for reflection in a severely time-limited setting. 2) How to facilitate knowledge translation regarding important treatment risks and benefits when patient and family capacity is blunted by the effects and shock of stroke. 3) How to ensure patient and family views are taken into account when the situation produces reliance on the expertise of clinicians. Strategies adopted to meet these conundrums were fourfold: face to face communication; shaping decisions; incremental provision of information; and communication tailored to the individual patient. Relational forms of interaction were understood to engender trust and allay anxiety. Shaping decisions with patients was understood as an expression of confidence by clinicians that helped alleviate anxiety and offered hope and reassurance to patients and their family experiencing the shock of the stroke event. Neutral presentations of information and treatment options promoted uncertainty and contributed to anxiety. ‘Drip feeding’ information created moments for reflection: clinicians literally made time. Tailoring information to the particular patient and family situation allowed clinicians to account for social and emotional contexts. The principal responses to the challenges of decision making about rtPA in hyperacute stroke were relational decision support and situationally-sensitive knowledge translation.

"We are always asked; 'where are you from?'": Chilean women's reflections in midlife about their health and influence of migration to Sweden

AIM

This study explored how Chilean immigrant women living in Sweden perceived and related their life situations and health status during midlife to their migration experiences.

METHOD

Three focus group discussions (FGDs) were performed with 21 middle-aged Chilean women (40-60 years) who had lived in Stockholm for at least 15-20 years. In-depth interviews were held with three key informants. A combination of manifest and latent content analysis was performed to structure and categorize the tape-recorded and transcribed data.

FINDINGS

Three main themes emerged from the data: (i) Chilean women's reflections about migration and resettlement; (ii) Health during midlife; perceptions of Chilean women living in Sweden; and (iii) Strategies to manage their lives and to gain social acceptance and position. The Chilean women reflected about the discrimination they had met in the Swedish society and within the health care system along with health changes they had had during midlife. They connected some of their health related problems to their hardships of migration. They also expressed confusion about the health care they had received in Sweden including conflicting and mistrusting relationship with some health care providers. Important for their way of coping with their own health seemed to be a recognition of their own space, level of independence, self-acceptance and awareness of power relationships.

CONCLUSION

The results illuminate the importance of awareness of influence of gender and socio-cultural aspects, power relationships and communication skills among health care providers on women's health. Complementary interventions to the biomedical paradigm are needed and should be addressed in Swedish health staff educational programmes as well as in clinical training.

Menopause narratives: the interplay of women's embodied experiences with biomedical discourses

Conventional approaches to menopause tend to contrast the biomedical position on menopause with women's actual experiences of it. Rather than focusing primarily on the tensions between these perspectives (biomedical vs. lay), our emphasis here is on the impact of biomedicine in shaping participants' perceptions of their status as menopausal. Based on interview data gathered from 39 women in Ireland, we argue that the cultural authority of biomedicine shaped participants' experiences of the body and how they constituted their health identity. We assert that, ironically, this was particularly the case among those who most strongly contested biomedical definitions of their situation. In addition, biomedical practitioners' definitions had a strong normalizing power in how the body was experienced. We conclude by noting that our analysis problematizes the notion of privileging "women's experiences" as advocated by some feminist perspectives. The heavy influence of biomedical discourses in shaping participants' embodied experiences demonstrates the pervasive impact of prevailing discourses on women's experiences.

Chilean midwives and midwifery students' views of women's midlife health-care needs

OBJECTIVE

to determine Chilean midwives' views with regard to Chilean women's health-care needs in midlife. The aim was also to explore Chilean midwifery students' views on the clinical care provided to women in midlife.

DESIGN

a qualitative study using focus group discussions and narratives which were analysed using thematic manifest and latent content analysis.

SETTING

10 different primary health care (PHC) centres in Santiago, Chile.

PARTICIPANTS

22 midwives, working in PHC clinics and 13 (n = 13) midwifery students with PHC clinical experience, attending their fourth or fifth year of midwifery education at the School of Midwifery in Santiago.

FINDINGS

the midwives felt that women in midlife have special health-care service needs. They also considered themselves to be the most appropriate health staff to provide health care for women in midlife, but recognised that they lacked competence in attending psychological and social health-care needs of women in midlife such as violence, abuse and sexuality issues. The midwifery students remarked that many midwives focused their attention on fulfilling the biomedical requirements. Even if the midwives had knowledge about recent research on menopause, they had difficulties in approaching this issue and including it in their counselling. Some students also questioned the sometimes disrespectful attitude shown, especially towards Peruvian immigrants and women with psychosocial problems.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

the findings suggest that midwives need more education about women's health-care needs in midlife, and that more focus should be placed on the psychosocial aspects of midwifery. More reflections about the quality of the client-provider relationship in clinical practice are needed. Gender issues, the structure of power relationships, and empowerment should be incorporated and critically discussed during midwifery education and training, and also in clinics.

Attitudes toward postmenopausal long-term hormone therapy

In this article we address the question of why postmenopausal women undergo hormone therapy. Thirty-five women aged 46 to 75 years living in Bremen (Germany) and taking postmenopausal hormones for at least 12 months were interviewed. Following Fritz Schütze, the interviews were analyzed according to a reconstructive analytical procedure. Five different types of users were identified. They differed from each other in terms of their reasons for using hormones, their expectations of this type of therapy, and their personal habits and circumstances, including an integrity-preserving attitude, a performance-oriented attitude, a searching attitude, a faith-in-medicine attitude, and a benefit-generalizing attitude. The interviews show that there is a need for target-oriented counseling, taking into account the individual attitudes toward menopause and postmenopausal hormone therapy.

Is it science? A study of the attitudes of medical trainees and physicians toward qualitative and quantitative research

This study examined the degree of acceptance of qualitative research by medical trainees and physicians, and explored the causes for any differences in their support of qualitative versus quantitative research. Thirty-two individuals at four levels of medical training were studied. Eight philosophers of science served for construct validation. After completing a questionnaire, participants were interviewed using a semi-structured procedure. Transcriptions of the interviews were coded for emergent themes. Coding consensus was achieved via iterative discussion. When asked to categorize 10 projects, participants on average ranked quantitative science projects as "more scientific" than those using qualitative methodologies. Although participants appeared largely unaware of the principles underlying qualitative methodologies, most expressed the belief that qualitative data was more biased and less objective than quantitative data. Prior qualitative research experience was the major predictor of acceptance of qualitative research. Participants' acceptance of interpretivistic or positivistic paradigms also influenced what type of science they felt was acceptable. Their level of training did not correlate with the acceptance of qualitative methodologies. On average, participants in our study favoured quantitative methodologies over qualitative methodologies. We postulate that this preference is due to their unawareness of the principles and paradigms underlying the methodologies.

Menopausal symptom experience: an online forum study

AIM

The aim of the study was to explore the menopausal symptom experience of White midlife women.

BACKGROUND

Recent cross-cultural investigations have indicated important ethnic differences in menopausal symptoms and have challenged the universality of these symptoms. Currently available cultural knowledge on menopausal experience, however, is inadequate to guide appropriate and adequate care even for White women in the menopausal transition.

METHOD

A cross-sectional qualitative online forum study was conducted in 2007 with 23 midlife women who self-identified as non-Hispanic Whites using convenience sampling. Seven topics related to menopausal symptom experience were used to guide the online forum for 6 months. The data were analysed using thematic analysis.

RESULTS

The experiences of menopause caused women to redefine themselves within their busy daily life schedules. They were optimistic about their symptoms, and tried to laugh at the experience to boost their inner strength and motivate themselves to persevere. Many thought that both generational and life-style differences were much more important than ethnic differences in menopausal symptom experiences. In seeking assistance with the symptoms of menopause, women were not satisfied with the guidance of their physicians.

CONCLUSION

Nurses need to listen carefully to what women themselves say about their own experiences with menopausal symptoms and avoid imposing predetermined symptom management strategies. Further studies of women's perceptions of life-style influences are needed to guide symptom management. In addition, studies of generational changes in menopausal symptom experience are needed.

A funny thing happened on the way to the journal: a commentary on Foucault's ethics and Stuart Murray's "Care of the self"

Stuart Murray's 'Care and the self: biotechnology, reproduction, and the good life' utilizes Foucault's "care of the self" to examine health domains in its title. The present author discusses three important articulations of concern with the Foucauldian concepts of care of the self that are absent in the work of Murray and others: first, the voluntarism and individualism inherent in ideas about care of the self; second, the absence of the interactional and relational; and, third, the perpetuation of the interpretation of Foucault's concept of governmentality, 'the conduct of conduct', as primarily coercive.

Hormone therapy, dilemmas, medical decisions

The decision for women to go on hormone therapy (HT) remains controversial. An historical oscillation of beliefs exists related in part to expectations of the medicinal value of HT over longer-term use beyond the initial peri-menonpausal period. Studies thought to resolve issues surrounding the efficacy of HT were perhaps overstated as confusion still permeates the decision making with regard to HT. Overzealous advertising and exaggerated understanding of the results (negative or positive) undermine patient and physician decision making. There remains no magic bullet with regard to HT. What remains is still the possibility of HT longer-term efficacy on diverse end organ systems with pockets of clinical and scientific ambiguity while working to engender reasonable expectations.

Flexible therapeutic landscapes of labour and the place of pain relief

Flexibility in the design and enactment of spaces of healthcare is important in how providers respond to variations in patient expectations and experience. Health geographers have contributed to a wide body of literature concerning the therapeutic qualities of landscapes and the material, social and symbolic orderings of place and their uniqueness for individuals. In this paper, we draw upon these findings and a 'culture of place' approach to consider the complexities of maternity care and issues of pain relief. Given that pain is widely held to be a subjective experience and one that, in an era of patient decision making, increasingly demands discretionary approaches to its relief, we consider how medical professionals help to construct flexibility in healthcare and how this affects therapeutic landscapes. Drawing on analysis of four focus groups involving parent educators, midwives, health visitors, anaesthetists and obstetricians in the NE of England, we explore the material and discursive construction of flexible therapeutic landscapes and pain relief. Our findings suggest that flexibility is constrained and fashioned in association with health care professional's sense of place as already constituted. We propose that providing maternity care professionals with an explicit awareness of how places are relationally constructed, may help in expanding the therapeutic qualities of particular settings, and support a (more) flexible approach.

A feminist approach to research on menopausal symptom experience

Despite an increasing number of feminist studies in the area of women's health, feminist approaches have rarely been used in nursing research on the menopausal symptom experience of midlife women. The purpose of the article is to propose a feminist approach to such research on the basis of a literature review. First, diverse feminist perspectives and their commonalities are summarized. Then, the literature related to the menopausal symptom experience is critiqued from a feminist perspective. On the basis of the discussion, 5 principles are proposed for a feminist approach to research on menopausal symptom experience.

Working behaviour of competent general practitioners: personal styles and deliberate strategies

OBJECTIVE

To study how competent GPs perform their work within the consultation and in relation to the team and practice organization.

DESIGN

Ethnographic study with thick description. A participant observation of the GP was followed by a personal interview. A substantial description was elaborated that was analysed qualitatively.

SETTING

Primary care surgeries in Sweden.

SUBJECTS

A number of competent GPs.

RESULTS

Two main categories emerged, deliberated strategy and personal style. These categories set up the individual pattern of working behaviour for each GP. A behaviour that is a deliberate strategy for one GP for the other belongs to his or her personal style. Common denominators in the overall working behaviour were attention to the patient as a person, practising patient-centred medicine, saving the consultations from disturbances, rejecting taking over responsibilities from the patients, and safeguarding own autonomy.

CONCLUSION

The transition of deliberate, favourable strategies into one's personal style is an important aspect of professional development. A well-developed personal style is necessary to obtain the spontaneous interchange between attentive listening and detachment characteristic of patient-centeredness.