Lisa Parker

The origins of height fear: an evaluation of neoconditioning explanations.

The present research sought to establish a reliable and valid instrument for assessing the relevance of neoconditioning factors (e.g. latent inhibition, UCS inflation/revaluation, prior fear levels, prior expectancies of harm, fear and pain levels experienced during supposed learning events), in the development of human fear. Fifty-four undergraduate height-fearful students completed the new origins instrument (OQ-II), while 54 matched controls completed a modified version (OQM-II) that examined their prior experiences with heights. In general, few differences between groups were found. Height-fearful and control subjects did not differ on trait anxiety, the frequency of negative encounters with heights, the age at which these events had occurred, prior fear levels, prior expectancies of harm, or reports of UCS inflation/revaluation procedures. However, in a finding directly opposite to that expected from a conditioning account, the mean fear and pain scores reported by subjects who had experienced direct conditioning events were significantly higher in the non-fearful group than in the height-fearful group. These findings are discussed in terms of associative and non-associative models of fear.

Screening for Cervical, Prostate, and Breast Cancer: Interpreting the Evidence.

Cancer screening is an important component of prevention and early detection in public health and clinical medicine. The evidence for cancer screening, however, is often contentious. A description and explanation of disagreements over the evidence for cervical, breast, and prostate screening may assist physicians, policymakers, and citizens faced with screening decisions and suggest directions for future screening research. There are particular issues to be aware of in the evidence base for each form of screening, which are summarized in this paper. Five tensions explain existing conflicts over the evidence: (1) data from differing contexts may not be comparable; (2) screening technologies affect evidence quality, and thus evidence must evolve with changing technologies; (3) the quality of evidence of benefit varies, and the implications are contested; (4) evidence about harm is relatively new, there are gaps in that evidence, and there is disagreement over what it means; and (5) evidence about outcomes is often poorly communicated. The following principles will assist people to evaluate and use the evidence: (1) attend closely to transferability; (2) consider the influence of technologies on the evidence base; (3) query the design of meta-analyses; (4) ensure harms are defined and measured; and (5) improve risk communication practices. More fundamentally, there is a need to question the purpose of cancer screening and the values that inform that purpose, recognizing that different stakeholders may value different things. If implemented, these strategies will improve the production and interpretation of the methodologically challenging and always-growing evidence for and against cancer screening.

Clinical ethics ward rounds: building on the core curriculum

The clinical years of medical student education are an ideal time for students to practise and refine ethical thinking and behaviour. We piloted a new clinical ethics teaching activity this year with undergraduate medical students within the Rural Clinical School at the University of New South Wales. We used a modified teaching ward round model, with students bringing deidentified cases of ethical interest for round-table discussion. We found that students were more engaged in the subject of clinical ethics after attending the teaching sessions and particularly appreciated having structured time to listen to and learn from their peers. Despite this, we found no change in student involvement in managing or planning action in situations that they find ethically challenging. A key challenge for educators in clinical ethics is to address the barriers that prevent students taking action.

The role of communication in breast cancer screening: a qualitative study with Australian experts

BackgroundOne well-accepted strategy for optimising outcomes in mammographic breast cancer screening is to improve communication with women about screening. It is not always clear, however, what it is that communication should be expected to achieve, and why or how this is so. We investigated Australian experts’ opinions on breast screening communication. Our research questions were: 1 What are the views of Australian experts about communicating with consumers on breast screening? 2 How do experts reason about this topic?MethodsWe used a qualitative methodology, interviewing 33 breast screening experts across Australia with recognisable influence in the Australian mammographic breast cancer screening setting. We used purposive and theoretical sampling to identify experts from different professional roles (including clinicians, program managers, policy makers, advocates and researchers) with a range of opinions about communication in breast screening.ResultsExperts discussed the topic of communication with consumers by focusing on two main questions: how strongly to guide consumers’ breast cancer screening choices, and what to communicate about overdiagnosis. Each expert adopted one of three approaches to consumer communication depending on their views about these topics. We labelled these approaches: Be screened; Be screened and here’s why; Screening is available please consider whether it’s right for you. There was a similar level of support for all three approaches. Experts’ reasoning was grounded in how they conceived of and prioritised their underlying values including: delivering benefits, avoiding harms, delivering more benefits than harms, respecting autonomy and transparency.ConclusionsThere is disagreement between experts regarding communication with breast screening consumers. Our study provides some insights into this persisting lack of consensus, highlighting the different meanings that experts give to values, and different ways that values are prioritised. We suggest that explicit discussion about ethical values might help to focus thinking, clarify concepts and promote consensus in policy around communication with consumers. More specifically, we suggest that decision-makers who are considering policy on screening communication should begin with identifying and agreeing on the specific values to be prioritised and use this to guide them in establishing what the communication aims will be and which communication strategy will achieve those aims.

Values in breast cancer screening: an empirical study with Australian experts

Objective To explore what Australian experts value in breast screening, how these values are conceptualised and prioritised, and how they inform experts’ reasoning and judgement about the Australian breast-screening programme. Design Qualitative study based on interviews with experts. Participants 33 experts, including clinicians, programme managers, policymakers, advocates and researchers selected for their recognisable influence in the Australian breast-screening setting. Setting Australian breast-screening policy, practice and research settings. Results Experts expressed 2 types of values: ethical values (about what was good, important or right) and epistemological values (about how evidence should be created and used). Ethical values included delivering benefit, avoiding harm, promoting autonomy, fairness, cost effectiveness, accountability, professionalism and transparency. Epistemological values informed experts’ arguments about prioritising and evaluating evidence methodology, source population and professional interests. Some values were conceptualised differently by experts: for example, delivering benefit could mean reducing breast cancer mortality, reducing all-cause mortality, reducing mortality in younger women, reducing need for aggressive treatment, and/or reassuring women they were cancer free. When values came into conflict, experts prioritised them differently: for example, when experts perceived a conflict between delivering benefits and promoting autonomy, there were differences in which value was prioritised. We explain the complexity of the relationship between held values and experts’ overall views on breast cancer screening. Conclusions Experts’ positions in breast screening are influenced by evidence and a wide range of ethical and epistemological values. We conclude that discussions about values should be a regular part of breast-screening review in order to build understanding between those who hold different positions, and provide a mechanism for responding to these differences.

Framing overdiagnosis in breast screening: a qualitative study with Australian experts

BackgroundThe purpose of this study was to identify how the topic of overdiagnosis in breast cancer screening is framed by experts and to clarify differences and similarities within these frames in terms of problems, causes, values and solutions.MethodsWe used a qualitative methodology using interviews with breast screening experts across Australia and applying framing theory to map and analyse their views about overdiagnosis. We interviewed 33 breast screening experts who influence the public and/or policy makers via one or more of: public or academic commentary; senior service management; government advisory bodies; professional committees; non-government/consumer organisations. Experts were currently or previously working in breast screening in a variety of roles including clinical practice, research, service provision and policy, consumer representation and advocacy.ResultsEach expert used one or more of six frames to conceptualise overdiagnosis in breast screening. Frames are described as: Overdiagnosis is harming women; Stop squabbling in public; Don’t hide the problem from women; We need to know the overdiagnosis rate; Balancing harms and benefits is a personal matter; and The problem is overtreatment. Each frame contains a different but internally coherent account of what the problem is, the causes and solutions, and a moral evaluation. Some of the frames are at least partly commensurable with each other; others are strongly incommensurable.ConclusionsExperts have very different ways of framing overdiagnosis in breast screening. This variation may contribute to the ongoing controversy in this topic. The concept of experts using different frames when thinking and talking about overdiagnosis might be a useful tool for those who are trying to negotiate the complexity of expert disagreement in order to participate in decisions about screening.

Using human tissue: when do we need consent?

Identifiable excess surgical tissue is an important resource for medical research but we have become overly restrictive about consent requirements. I suggest we devolve consent to ethics committees for ordinary research projects involving human tissue, retaining the requirement for explicit consent only for those sensitive research situations where there is significant risk of harm to individual interests in privacy.

Ethical drug marketing criteria for the 21st century

Lisa Parker and colleagues call for WHO to expand and update its criteria for ethical drug promotion to take account of changing marketing practices

How we involved rural clinicians in teaching ethics to medical students on rural clinical placements

Abstract Background: The task of engaging senior medical students in ethical inquiry while on rural clinical placements has received minimal attention in the medical education literature. As there is an international trend for medical students to undertake part or all of their clinical training in rural areas, the need to deliver clinically relevant ethics teaching in a sustainable manner has emerged as a challenge for medical schools. Clinicians tend to be hesitant about delivering this kind of teaching. What we did: We introduced a novel teaching program which involved recruiting, training and supporting experienced rural clinicians to facilitate a series of Rural Ethics Ward Rounds with the senior medical students on extended rural placements. Evaluation: The clinical facilitators expressed some initial uncertainty with the teaching model, but generally reported a positive experience, including significant professional benefits such as increased ethical awareness and opportunity for self-reflection. Conclusion: This model enables experienced rural clinicians to facilitate student development in ethical awareness and skill, and requires relatively low demands on academic time and resources.

Avoiding harm and supporting autonomy are under-prioritised in cancer-screening policies and practices

The ethical principles of avoiding harm and supporting autonomy are relevant to cancer-screening policy. We argue that more attention needs to be given to implementing them. Cancer screening may deliver excessive harms due to low-value or outdated screening programsxa0and from poorly communicated screening options that leave people with heavy burdens of decision-making. Autonomy is inadequately supportedxa0due to limited opportunities for people to understand downsides of screeningxa0and because of institutional and societal pressures in favour of screening. Members of screening policy committees may have differing ideas about the goals of screeningxa0or have conflicts of interest that prevent them from addressing policy questions in a neutral way. We recommend the following: 1. Committees should be required to discern and discuss the values of individual members and the wider public; 2. Committee membership and voting procedures should be more carefully constructed to reduce the likelihood that committee members interests are placed above public interests; 3. Committees should explain their policy decisions with reference to values as well as evidence, so that values considered in decision-making can be interrogated and challenged if necessary. These changes would increase the likelihood that cancer-screening policy decisions are in keeping with public views about what is important.