Ethical relationships in paediatric emergency medicine: moving beyond the dyad

Designing family-centered male circumcision services: a conjoint analysis approach

BACKGROUND

Male circumcision (MC) has become an important weapon in the fight against HIV/AIDS in many Sub-Saharan African countries. The successful implementation of a national MC program requires the design of circumcision services that are attractive to young men of various ages. For many potential clients, mothers and/or fathers will play an important role in the decision to be circumcised, and hence services will need to be designed with the preferences of mothers, fathers, and sons in mind.

OBJECTIVE

Our objective was to value multiple design characteristics of potential community-based MC services from the perspectives of mothers, fathers, and sons in Johannesburg, South Africa, and to test for concordance between their values for the design characteristics.

METHODS

Potential design characteristics of MC services were identified through open-ended interviews with key informants (n = 25). Preferences were estimated using conjoint analysis implemented as part of a cluster randomized household survey. Each participant was randomized to receive one of two possible blocks of conjoint analysis, each consisting of six forced-choice tasks comparing two possible MC services varying on 11 design characteristics. With only two levels for each attribute, our experimental design utilized a main effects orthogonal array. Data were analyzed using linear probability models, with tests of concordance of values using Wald tests generated from stratified estimates calculated using restricted least square estimation.

RESULTS

A racially and geographically diverse sample consisting of 204 fathers, 204 mothers, and 237 sons completed the survey. In aggregate, requiring a follow-up visit was the most valued design factor (p < 0.001), followed by having a lower infection rate (p < 0.001), having less pain (p = 0.001), and a private waiting room (p = 0.001). Based on stratified analysis, sons also valued having the risks and benefits of MC explained (p = 0.01) and mothers valued requiring an HIV test as part of the procedure. Requiring an HIV test was the most significant difference between the respondents (p = 0.03), with sons finding it somewhat repulsive (p = 0.30).

CONCLUSION

Our findings suggest that valuation of aspects of MC clinic design can diverge by decision maker. To better ensure utilization of services, these variations should be taken into account to prior to implementation of a national strategy in South Africa.

Ethical principles--emergency medicine

Neither law nor religion, bioethics absorbs and applies elements of both. Its theories, principles, and methods stem from various philosophical schools. Practitioners use case-based reasoning to apply bioethics to clinical situations, usually giving most weight to patients' autonomy and values, but also incorporating other relevant bioethical principles, including those encompassed in professional oaths and codes. Emergency clinicians must be able to recognize bioethical dilemmas, have action plans based on their readings and discussions, and have a method through which to apply ethical principles in clinical settings. This article provides an overview of ethical considerations and guidelines for emergency clinicians.

Issues involved in promoting patient autonomy in health care

Respecting patient autonomy is a central part of the Royal College of Nursing's definition of nursing (RCN, 2003). Although autonomy is a fundamental ethical principle in health care, it stands alongside the principles of beneficence, non-maleficence and justice (Wilmot, 2003), and these principles may be interpreted differently by individuals and professional groups. In seeking to promote patient autonomy, it is therefore necessary for nurses to consider how these principles interlink, and to understand the potentially differing interpretations that they may encounter in practice. This article sets out to address these issues and suggests that facilitating patient autonomy includes engaging in debates which include uncertainties, considering the resource implications of patient autonomy and the responsibilities that patients have themselves. It also identifies that nurses who aim to promote patient autonomy and holistic decision making need to be able to facilitate discussion that may include questioning the dominant biomedical view of health. This will be problematic if nurses do not themselves feel empowered or autonomous.