GCF Chan

In medical ethics, the criteria of medical conditions that lead to the decision of "therapeutic abortion" are not always as discrete as "black and white" especially with the advances of medical and surgical management. For complex congenital anomalies with severe functional consequence, there is not as much controversy putting aside the religious debate. However, in recent years, many diseases used to be considered as absolute indication for abortion are becoming treatable with excellent outcome, that includes haemophilia, thalassaemia, selected metabolic disorders and some forms of congenital heart disorders. Patients can have normal function and good quality of life with appropriate management. The approach now is to adopt a "non-directive" advice related to the option of abortion. However, isolated cleft lip/palate should not even fall into such category solely on medical ground. For this condition, we can often achieve satisfactory esthetic and functional result with proper surgical intervention after birth. If it can be diagnosed antenatally, a multi-disciplinary antenatal counseling can improve the parental acceptance of this birth defect and minimise the abortion rate as suggested by the article of Tang et al. The list of conditions that allows "therapeutic abortion" should be revisited regularly and update in the future. Doctors or nurses engage in antenatal counseling should also keep up with the progress in management and prognosis of different diseases so accurate information can be conveyed to the parents involved.

Another ethical dilemma in medical practice is to obtain the consent in performing invasive investigational procedure. When should we perform a lumbar puncture in patients who present with febrile seizure without clinical manifestation of meningitis? The argument in the past was that children may not express themselves very well and the presentation of meningitis can be atypical in young children. Therefore, lumbar puncture should be performed if the diagnosis of meningitis cannot be ruled out. The study by Kanik et al showed that if patients do not have clinical manifestation of meningitis, the chance of capturing meningitis by performing lumbar puncture in a child presenting with either simple or complex febrile seizure is very remote. The same will be true for infant with fever, the traditional concept of performing the "3 big tests" including blood culture, suprapubic tap and lumbar puncture as gold standard for all febrile infants should also be challenged by thorough clinical study to verify its legitimacy.

With the advance of molecular genetic technology, it raises a question as of how should we adopt the genetic information into our routine clinical practice. Is it ethical to suggest or propose whole genome or whole exon sequencing for all individual so we can provide patient specific health related information to our patients in a nutshell? Even if the bioinformatics and economic bottleneck will probably not an issue in the future, such approach may potentially touch on the ethical issue in medical practice. The article of Luo et al illustrated one of such issues which is the clinical application of genetic information in predicting the disease risk of a population. Genetic polymorphism in vitamin D associated genes including vitamin D binding protein (DBP) and vitamin D receptor (VDR) have been advocated by the UK investigators to be associated with the risk of developing Crohn's disease among Caucasians but such association cannot be replicated in the Chinese cohort. This suggests that genotype phenotype correlation is a complex event and many confounding factors may influence the outcome. Using such information to predict disease risk may be misleading if the data has not been fully validated. It may also induce significant impact on medical insurance eligibility and premium calculation. Consensus should be made among the experts involved and come up with clear guidelines on this practice.

Another aspect of medical ethics is research ethics, it is understood that trials involving potential risk and harm to the subjects have to be approved by the institutional ethic committee before it can be launched. However, in recent years, retrospective chart review and questionnaire survey also requires ethical committee approval. Even questionnaire-based research does not have the same psychological or physical risks to participants as experimental trials, there are concerns on the ethical aspect and it actually begins with the design. For example, research questions should be objective and leading questions should be avoided. Surveys and interviews should not contain hypothetical questions or induce embarrassment to the respondents. Respondents should be adequately informed of the purpose of the research and allowed the respondants to ask questions or quit. Confidentiality has to be protected at all time. Preferably a debriefing session should be provided to answer participants' questions or to provide support to anyone negatively impacted by the study. This is exemplified by the article of evaluating how adolescents in Hong Kong perceived the weather effects on their mood and emotion. Though it is a relative straight forward non-invasive survey and the results are non-controversially agreeing with the conventional wisdom that good weather is associated with good mood, approval from related ethical committee has been obtained. This study high-lighted the current trends in research ethics to be followed.

Finally, this issue also consists of the practice recommendations for management of community acquired pneumonia in children by a group of paediatric infectious disease experts. With the wide spread emergence of resistance strains due to antibiotic abuse, this recommendation provides guidance for both paediatricians working in either hospital or private setting to make reference. Though we do not use the term guideline due to the legal implication, most of the recommendations are evidence based and can be easily followed by paediatricians both working in public or private settings. Therefore, it is a basic medical ethic that we have to be aware of this recommendation and understand the current standard practice.

Medical ethics is not something that is philosophical and theoretical; it is actually intimately involved in our daily medical practice as illustrated by the above scenario. This is our moral obligation to adhere to at all time as a medical professional.