Pekka Louhiala

End of life decisions: attitudes of Finnish physicians

Objectives: This study investigated Finnish physicians’ experiences of decisions concerning living wills and do not resuscitate (DNR) orders and also their views on the role of patients and family members in these decisions. Design: A questionnaire was sent to 800 physicians representing the following specialties: general practice (n = 400); internal medicine (n = 207); neurology (n = 100), and oncology (n = 93). Results: The response rate was 56%. Most of the respondents had a positive attitude toward (92%), and respect for (86%) living wills, and 72% reported situations in which such a will would have been helpful, although experience with their use was limited. The physicians reported both benefits and problems with living wills. Thirteen per cent had completed a living will of their own. Half did not consider living wills to be reliable if they were several years old. Do not resuscitate orders were interpreted in two ways: resuscitation forbidden (70%) or only palliative (symptom oriented) care required (30%). The respondents also documented DNR orders differently. Seventy two per cent discussed DNR decisions always or often with patients able to communicate, and even 76% discussed DNR orders with the family members of patients unable to communicate. Most respondents were able to approach a dying patient without difficulty. They also felt that education in general was needed. Conclusions: In general Finnish physicians accept living wills, but find they are accompanied by several problems. Many problems could be avoided if physicians and patients conducted progressive discussions about living wills. The differing interpretations of DNR orders are a matter of concern in that they may affect patient treatment. The promotion of patient autonomy with respect to treatment seems rather good, but the limitations of the study need to be kept in mind.

What do we really know about the deliberate use of placebos in clinical practice

The aim of the present study was to explore the use and understanding of the concepts ‘placebo’ and ‘placebo effect’ in 12 empirical studies that have addressed the prescription of placebos by doctors in clinical practice. There were great differences in the general methodology and in the definitions (or lack of any definition) of the basic concepts in these 12 studies. Therefore, the results reflect different things. They tell us a little about the use of ‘pure placebos’, more about the use of ‘impure placebos’, but most of all, they tell us about the conceptual confusion in this area.

RISK INDICATORS OF MENTAL RETARDATION: CHANGES BETWEEN 1967 AND 1981

The object of this case‐control study was to investigate and analyse perinatal risk indicators of mental retardation. Data concerning 33 perinatal factors possibly related to mental retardation were collected retrospectively for the population of an area in Finland. The subjects were 339 cases born between 1967 and 1981 with mental retardation of suspected perinatal or unknown aetiology and 364 controls born in the same period. Independent risk indicators were low maternal social class, multiparity, multiple pregnancy, male sex, being born small for gestational age, asphyxia, hypoglycaemia and hyperbilirubinaemia in the newborn infant. Perinatal problems increased the risk for multiple disabilities. Preterm birth under 33 gestational weeks and very low birthweight (<1500g) were associated with considerable risk, bul neither was an independent risk indicator. The introduction of neonatal intensive care seems to have altered the risk of death to the risk of surviving with disability.

Finnish physicians’ attitudes towards active euthanasia have become more positive over the last 10 years

Introduction Most physicians are against active euthanasia. Very little is known about the possible changes in the attitudes of physicians. Methods A questionnaire was sent to a random sample of 1003 Finnish physicians of working age. A similar questionnaire had been sent to a random sample of Finnish physicians also in 1993 and 2003. The questionnaire consisted of statements about euthanasia, for which the participants were asked to express their agreement or disagreement on a 5-point Likert scale. Results In general, Finnish physicians’ attitudes towards active euthanasia have become considerably more positive. In 2003, 61% of the respondents were against the legalisation of euthanasia and 29% supported it. In 2013, both groups were of equal size (46%). The willingness to perform active euthanasia has not, however, increased significantly, even in a legalised setting. Conclusions The attitudes of Finnish physicians towards active euthanasia became considerably more positive between 2003 and 2013. There was no significant change, however, in the willingness to practice euthanasia if it became legal.

There is no alternative medicine

The term ‘alternative medicine’ is a misnomer because it suggests that there are two kinds of medicine alternative to each other. Although commonly used, the term is problematic. It escapes a meaningful definition, and ‘alternative medicine’ cannot be clearly differentiated from ‘conventional medicine’. The nature of ‘alternative’ in ‘alternative medicine’ is anything but clear. In addition, bundling all the so-called alternative therapies under one heading is misleading. Due to the purely rhetoric nature of the ‘alternativity’, there seems to be no such thing as ‘alternative medicine’ in any meaningful sense.

Can CAM treatments be evidence-based?

In this essay, we first take a critical look at the definitions of evidence-based medicine (EBM) and complementary and alternative medicine (CAM). We then explore the question of whether there can be evidence-based forms of CAM. With the help of three examples, we show that EBM and CAM are not opposites, but rather concepts pointing at different dimensions. Each of the three examples is an evidence-based treatment according to three to five randomized, doubleblind placebo controlled trials with consistent findings and narrow pooled confidence intervals. The most reasonable interpretation for the existence of evidence-based CAM treatments seems to be that the opposite of CAM is ‘mainstream medicine’, and the demarcation line between CAM and mainstream medicine is not defined by the question of whether a treatment works or not. Some effective treatments may belong to the CAM field for historical reasons and because of preconceptions within mainstream medicine. Therefore, some treatments that currently lie outside mainstream medicine can be evidence-based.

Finnish doctors and the realisation of patient autonomy in the context of end of life decision making

Patient autonomy is a fundamental principle in end of life decision making. However, its realisation may take a variety of forms. Discourse analysis was conducted in a qualitative interview study of 19 physicians. The physicians made use of three different discourses, each of which contained a specific understanding of patient autonomy and a physician’s proper activities in the context of end of life decision making.

Clinical use of placebo treatments may undermine the trust of patients: a response to Gold and Lichtenberg

There is an obvious need for a critical discussion of the concepts ‘placebo’ and ‘placebo effect’. In a recent paper on the use of placebos in clinical medicine, Gold and Lichtenberg note the conceptual difficulties but use the terminology in a confused way throughout their paper. In our response, we demonstrate these problems with a few examples from their paper.

On the ethics of oestrogen treatment for tall girls: an update

New empirical evidence on the long-term effects of oestrogen treatment for tall adolescent girls has shown that the intended psychosocial benefit of the treatment may not have been realised. This paper describes recent trends in the prevalence of the treatment and the results of a large Australian cohort study evaluating girls assessed between 1959 and 1993 for excessive growth. The paper concludes that oestrogen treatment to prevent extreme tallness should belong to the past, not to the future.

Impure placebo is a useless concept

Abstract Placebos are allegedly used widely in general practice. Surveys reporting high level usage, however, have combined two categories, ‘pure’ and ‘impure’ placebos. The wide use of placebos is explained by the high level usage of impure placebos. In contrast, the prevalence of the use of pure placebos has been low. Traditional pure placebos are clinically ineffective treatments, whereas impure placebos form an ambiguous group of diverse treatments that are not always ineffective. In this paper, we focus on the impure placebo concept and demonstrate problems related to it. We also show that the common examples of impure placebos are not meaningful from the point of view of clinical practice. We conclude that the impure placebo is a scientifically misleading concept and should not be used in scientific or medical literature. The issues behind the concept, however, deserve serious attention in future research.