Privacy and confidentiality are extremely important in the contemporary healthcare system, especially in relation to family and child counseling. Today, it is necessary to research implications of the introduction of confidentiality and privacy in health care environment. Basically, the problem of privacy and confidentiality refers not only to ethical but also legal issues since healthcare professionals are obliged to maintain the confidentiality and protect private information of patients from breaches. However, healthcare professionals may face a dilemma between preserving privacy and confidentiality of children counseling and treatment and the natural desire of parents to get all information about the treatment and the state of their children.
Introduction
First of all it should be said that the privacy and confidentiality is guaranteed to any patient, regardless his or her age, social position, race, etc. In the last years relations between doctors, patients and wide public suffered considerable changes. Although a doctor must operate in behalf of a patient conformable to the conscience, the corresponding guarantees of the autonomy and just attitude toward the patient are also needed.
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The most meaningful international “sources” of rights for citizens in the area of medicine are: the Lisbon declaration of the World medical association about the rights of patients, adopted on the 34th session of the World medical assembly (Lisbon, Portugal, September/October, 1981, with bringing of the amendments on the 47th session of the General assembly, Bali, Indonesia, September, 1995) and the Declaration about the policy in the area of providing of rights for a patient in Europe (European conference on rights for patients, Amsterdam, March, 28-30, 1994. World Health Organization, the European regional bureau).
According to the indicated documents all patients have the following rights while providing the medical care: the right for high-quality medical help; the right for freedom of choice; the right for the informed consent; the right to inquire the opinion of another doctor on any stage; the right of self-determination; the right for information; the right for confidentiality; the right for the medical-social education; the right for dignity; the right for religious help and assistance.
Attitude toward the patient must always be built with the maximal account of his interests; the applied treatment must correspond to the generally accepted and ratified medical principles.
Confidentiality of medical information
Confidentiality of medical information is the confidenceness and secrecy of information, reported by a patient to the medical worker at an appeal and receipt of medical care.
Medical secret is the data, not subjected to the disclosure, about the fact of appeal of a patient for medical help, diagnosis, and another information about the state of his health and private life, received as the result of inspections and treatments, prophylaxis and rehabilitation.
At an appeal for medical help and its receipt a patient has the right for maintenance in the secret of information about the fact of appeal for medical help, about the state of health, diagnosis and another information, got at his examination and treatment, and also on the choice of persons, whom in behalf of the patient the information about his state of the health may be given to.
In the case of violation of rights for a patient he can apply with a complaint directly to the leader or another public servant of medical and preventive establishment in which the medical care is given to him, to the corresponding professional medical associations and licensed commissions or to a court.
The right of the citizens for the confidentiality of the information transferred by them at an appeal and receipt of medical care, and also another information, making the medical secret, generates the responsibility of medical workers and another persons for its disclosure.
As it has already been said every person has the right for confidentiality and privacy. And it does not matter if the patient is a child or a grown-up, because children are also individuals and they also have rights. This is confirmed by documents. All the identified information about the state of patient’s health, diagnosis, prognosis and treatment, and also any another information of the personal character is considered to be confidential even after the death of the patient. In exceptional cases the descendants may get a title access to the information, concerning the risk of the inherited diseases.
The confidential information may be divulged only in the case that the patient will give a direct consent or such disclosure is directly foreseen by the law. The information may be revealed to other establishments of health protection exceptionally when it is necessary, if the patient has not given a direct consent.
All the identified information about the patient must be guarded. The defence of information is carried out in accordance with the order of their storage. The persons whom the identified information may come from must be protected in the analogical order.
All the information about the state of health of the patient, diagnosis, prognosis and treatment of his disease, and also any other information of the personal character must be kept in secret, even after the death of the patient.
The confidential information may be exposed only when there is a clear expressed consent of the patient for this, or it is required by the law. The consent of the patient is assumed to opening of confidential information to the medical personnel, taking part in treatment of the patient.
All the data that are able to declare the identity of the patient must be protected. The degree of defence must be in the adequate form of storage of the data. The parts of the human body, from which it is possible to extract the identification information, also must be kept with the observance of requirements of defence.
The patients have the right for the access to the medical report, and also to all the materials, that concern the diagnosis and treatment. The patient has the right to get the copies of these materials. However the data concerning the third persons must not become accessible for the patient.
The patient has the right to demand the correction, addition, clarifications and/or the exclusion of the data of the personal and medical character, if they are inexact, unfull or does not relate to the explanations of the diagnosis and realization of treatment.
Any intruding in the questions of the personal and domestic life of the patient is forbidden, except for those cases, when the patient does not object against it and the necessity of the encroachment is dictated by the aims of diagnostics and treatment.
In any case, the medical intruding in the personal life of the patient surely supposes the respect of his secrets. That is why such encroachment should be carried out only in the real presence of the strictly necessary for its realization persons, if the patient will not wish something other.
The patients, coming and entering the medical and preventive establishment, have the right to count on the presence of inventory and equipment in this establishment, necessary for the guarantee of the maintenance of medical secret, especially in those cases, when the medical workers provide care, accomplish the research and medical procedures.
On the other hand, this formal protection of the private information of children patients comes into clashes with the insistence of parents who are unwilling their child or children having any secrets from them, especially if the health of children is under concern. In this respect, it should be said that children, unlike adult patients, do not have absolutely identical rights since they are not fully responsible for their actions and their personality is not fully shaped. As a result, it is parents of children that are responsible for them and, therefore, they have larger rights to get access to information concerning their children, their health and treatment.
Reception of information
The persons under age have the right for the receipt of necessary information about the state of their health in an accessible form for them; here the minors have the right for the voluntarily informed consent to the medical interference or refuse from it. The necessary precedent condition for the medical interference is the informed voluntarily consent of the citizen.
The consent to the medical interference in regard to the persons, not attaining majority, give their legal representatives, i.e. parents after revealing them the information. In default of legal representatives a concilium makes decision about the medical interference, and at the impossibility to gather a concilium the directly treating (attendant) doctor does it with the subsequent notification of public servants of the medical organization and legal representatives of the patient.
A citizen or his legal representative has the right to refuse the medical interference or to demand its stopping. At refuse from the medical interference the possible consequences must be explained to the citizen or his legal representative in an accessible for him form. The refuse from medical interference with pointing of possible consequences is formalized by a record in the medical documentation and is signed by the citizen or his legal representative, and also by the medical worker.
At the refuse of parents or other legal representatives of a person, not attaining adult age, from medical care, necessary for the rescue of life of the indicated persons, the hospital establishment has the right to appeal to the court for defence of interests of these persons.
The right of the citizens for keeping in secret the information about the fact of appeal for medical help, about the state of health, diagnosis and another information, making a medical secret, generates the duty of medical workers and other persons, having an access to this information, to providing of its confidentiality.
If a patient is under age or incapable on some other reasons, the consent of the legally appointed representative is required, when such possibility is foreseen by the legislation. Nevertheless, a patient must take a direct part in decision-making in a maximally possible volume.
If an under age patient is able to accept rational decisions, his decisions must be taken into account and he has the right to forbid the disclosure of information to his legally appointed representative.
If the legally appointed representative or a person, authorized by the patient, does not give consent to treatment, which, in opinion of the doctor, answers the interests of health of the patient, the doctor is necessary to contest the indicated decision in corresponding legal or another establishment. In an extraordinary situation the doctor is necessary to operate in behalf of health of the patient.
So, from the said above we can make a conclusion that children have also rights for privacy and confidentiality but parents, who are responsible for them, have the right to know about the state of health of their children and about their medical treatment.
One of the most spread medical problems in the United States is the problem of obesity among school children.
The epidemic of obesity is one of the major problems of health protection. For the last two decades the indexes of prevalence of obesity grew almost in three times. In the countries of the WHO the half of adult population and every fifth child have the surplus mass of body, and the third from them already suffers obesity, here the number of such persons increases in rapid rates. The overweight and obesity play a considerable role in the development of many uninfectious illnesses, result in reduction of the expected life-span and render the unfavorable affecting quality of life. Every year diseases, related to the surplus mass of body, become reason of more than one million cases of death.
An especially anxious tendency is observed among children and teenagers, that conduces to strengthening of epidemic among the adult population and creates a really big threat to the health of our future generations. The annual rates of growth of indexes of prevalence of obesity among children continuously increase and presently exceed the level of 1970 to ten times.
Professor Recep AkdaÄŸ, for example, marks that obesity is one of the major problems of community health care in the twenty the first century. Use of the integral approach to the solution of this problem, for which he comes forward, will allow to take into account all its aspects: violation of feed, physical activity, and also socio-economic factors and development of policy in this area – examining them from the point of view of epidemic distribution of this problem, being beyond the temporal and national borders. In particular, the growth of epidemic of obesity among children and teenagers is a threat to the health and welfare of future generations.
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Mr. Recep Tayyip Erdogan, prime minister of Turkey, pays attention that the problem of obesity lies down as a heavy burden both on the systems of health protection and on the economy of countries. In particular, he expressed a concern about the consequences of obesity for the health of children, and also frequency of cases of premature death, related to obesity. He marks that he does not believe in the efficiency of the simplified approaches, such as a simple motive of people “to eat more healthy food and not to engage anymore in physical exercises”.
Michelle Obama says that one of the most serious dangers for our future is an epidemic of obesity of children in America. This problem disturbs her not only as the First lady, but as a mother. The truth is that children have not done themselves obese. They are fed by parents like this; they are fed at school like this. Children do not produce foods in which there is too much sugar or salt. And however they ask pizza, fried potato and candies, the decision depends on adults, on us.
So, let us clarify what is obesity. Presence of surplus amount of fat in an organism is called obesity. This state, usually determined as an overweight, presents a serious danger for the physical health of people. Statistical data of different insurance companies beyond controversy testify that considerable obesity is attended with an enhanceable death rate from the row of heavy diseases. Researches, conducted by G. Mayer and his employees in the Harvard University, showed that obese girls-teenagers possessed the same psychological features that persons, belongings to the minorities, exposed to discrimination. Obese young girls are not only too concerned by the state but also differ in passivity, fearing a hostile relation to itself. These fears are fed by the real displays of antipathy from the side of surroundings. Moreover, fashion-papers and movies with the participation of very thin models and actresses, propaganda in newspapers and magazines of diets for slimming and obtrusive advertising of quack receptions, pills and recipes for the decline of weight increase the psychological danger which suffering from obesity young people are exposed to.
The estimations of prevalence of obesity depend on the used criteria. For example, let’s remember that in 1950-1952 Ministries of health of the USA conducted the research of frequency of overweight among an adult population, using tables height/weight. The percent of people with an overweight hesitated from 9 to 40%. Nevertheless the amount of the inspected was not too great, except for the cities of Atlanta (something about 140 000 persons) and Richmond (something about 36 000 persons, and from them 12% with an overweight).
At the inspection of children in the district of Boston it turned out that the frequency of the sharply expressed obesity exceeded 26%. The danger consists in the habit to the wrong feed and the overweight in child’s age may be also saved in youth and further – for adults, when it is already contingently with evident consequences for human’s health. More and more specific data show that obesity in child’s and juvenile age combines with the early displays of atherosclerosis – disease, characterized by the deposit of fatty matters on the walls of arteries.
The overweight in childhood is a predecessor of obesity in the adult age. The row of associate physical and emotional problems accompanying obesity may last all the life, in particular case for women. Moreover, the probability of obesity for adults in this case increases: 50% of children which had an overweight in 6 years become obese by adults; in teens this probability increases to 80%.
The paediatrician Frank Ð. Franklin the medical director of the UAB/Children’s Hospital Children’s Center for Weight Management considers that years are needed for the side effects of obesity to develop, but some children of early age also may suffer from serious diseases. Medical states such as a diabetes mellitus of the second type, apneustic breath, hypertension and risk of atherosclerosis factors, meeting before almost exceptionally for adults, now appear for children with the surplus mass. Early interference, till the stereotypes of feed and way of life are fixed, reduces the chances of proof obesity and complications related to it.
The prevalence of obesity in the USA gained the character of epidemic. The data for 1999 – 2000 of the National Health and Nutrition Examination Survey (NHANES) show, that in the period between 1960s and the end of 1990s the amount of children with obesity in the age from 6 to 11 years has more than tripled, increasing from 4% to 15.3% (JAMA. 2002;288: 1728-1732). This tendency was saved for children in the age from 12 to 19 years, during this interval of time the prevalence grew from 5% to 15.5%. The fascination of prevalence is most of all expressed in the Americans of Mexican origin and teenagers-Afro-Americans. Gender features are not found out.
Presently, one of 5 children in the USA has an overweight according to the last data of NHANES, children begin to suffer from the overweight earlier. More than 10% of under-fives suffer from the overweight – Franklin says. Thus, additionally 15% of children and teenagers in the age from 6 to 19 years are exposed to the risk of obesity.
In 2000 the Centers for Disease Control and Prevention – CDC worked out the diagrams based on body mass index (BMI), for determining the surplus weight in the child’s age. The maps of the height worked out by CDC determine normal vibrations of BMI for the individuals in the age from 2 to 20 years, explains Franklin. BMI for children must be determined annually for all the children. A doctor must measure the arteriotony, glucose and cholesterol for the children with an overweight with the purpose of diagnostics of secondary complications, and also the level of triglycerides.
The dramatic increase of prevalence of surplus mass for children is “fed” by many socially-ethics factors, including the increase of variety of food, size of portions and electoralness in food, as well as by the increase of consumption of sweetened drinks and decline of physical activity. The endogenous cases of obesity are rare, Franklin underlines. Genetic syndromes, including Cohen and Bardet – Biedl, are presented by dismorphic features and delay of development in addition to obesity. The deceleration of height in length is related to the syndrome of Prader – Willi and endocrine reasons of obesity, such as hypothyroidism and syndrome of Cushing. A normal height in length is not characteristic for these states, Franklin marks. Moreover, children with the idiopathic increase of body mass are often higher than the average height (for their age), and often have domestic anamnesis burdened by obesity.
Children with an overweight must be examined on the concomitant pathology. Under the concomitant pathology one understands the diabetes, obstructive apneustic breath, illnesses of skin, orthopaedic problems related to the weight, cholelithiasis, depression and cardial risk factors.
Obesity can be classified by its etiology (by the origin) on genetically conditioned, at which heredity comes forward on the first plan; traumatic, conditioned by the damage of a certain area of cerebrum, namely hypothalamus, by endocrine diseases or psychical disorders; and exogenous, developing as a result of immobility or surplus of fats in the feed (this type of obesity is also observed at some types of animals). Different etiologic factors, doubtless, co-operate with each other in a great degree. For example, “genetic” obesity shows up only in condition of the sufficient feed.
Obesity can be also classified by the mechanism of its development. On this basis criterion, we may distinguish the “regulator” types of obesity, which the cerebral focis of adjusting of the appetite are broken at, and “metabolic”, related to the metabolic disturbance. According to Cornette (2008) “the states, characterized by turbo speed of synthesis of fats in an organism, by violation of their use (oxidizations), and also braking of selection of glucose by the liver are related to the last.” Such metabolic changes also result in the increase of appetite.
Experiments on animals, mainly on mice, showed the existence of many varieties of both regulator and metabolic obesity. Although classification of obesity for a man only begins, it is not eliminated that it may be based on the same principles. It is also possible, that the regulator obesity is the most widespread for a man; the insufficient physical activity belongs to the number its reasons.
Modern information about the mechanisms of adjusting of appetite does not allow to understand for a while up to the end how the different types of obesity development for a man. However it is quite clear, that this regulator system is extraordinarily difficult.
In 1912 the prominent American physiologist W. Cannon showed that privation of food caused rhythmic reductions of stomach; strong reductions are accompanied by the unpleasant feelings which are one of the elements of sense of hunger. The French pathologist G.Roussy discovered at this time, that the damage of hypothalamus (small area of brain, being situated at once above a hypophysis) promoted an appetite for a man, resulting sometimes in voracity. Later G.Brobek and B. Anand in the University of Yale found out in the hypothalamus the areas, called lateral focis; at destruction of these focis an animal stopped eating. In future Ð-. Mayer showed that some areas of cerebrum, called satiations of saturation, controlled the hungry reductions of stomach, and also braked the activity of lateral focis. It was also set, that after eating the sense of satiation, i.e. gap-fillingness of stomach, arising up at once, formed with the participation of the row of neurohormonal reflexes.
It is clear, that such a difficult mechanism, having metabolic, endocrine, neurological and psychological aspects, may be broken by many methods. The next example shows that even easy violations in time affect very noticeably. So, 500 g of fatty fabric for a man are equivalent to approximately 3500 calories. Power inputs at moderate physical activity are made by 3000 calories a day. If one consumes 3100 calories a day, that only on 3% exceeds expenses, then it will give the increase of about 5 kg of fat in a year.
It is set, that for children, who have one of the parents suffering from obesity, the frequency of the overweight is much higher, than for those who have thin parents, and among children who have both parents suffering from obesity, the frequency of the overweight arrives to 80%. Between the bodyweight of adopted children and parents, even if the adoption happened in the first months of the child’s life, the correlation is rather weak or quite absent. Finally, it is shown that the persons of a certain build are much more predispositioned to obesity, than the others, and the build, as it is generally known, is determined genetically.
Having studied the question of obesity I have my opinion on its treating. Any person, aspiring to be delivered from obesity, must foremost understand that it is conditioned by surplus of calories, i.e. it arose up because during some time the consumption of food exceeded the power inputs. The decline of weight may be obtained by either diminishing of consumption of food (by the observance of diet), either increasing of power inputs (by physical exercises) or combination of the first and the second.
As it was already mentioned, 500 g of fatty tissues are equivalent to something about 3500 calories. So, to lose this amount of fat, a deficit is needed in 3500 calories. Let us suppose that a child for the indemnification of his power inputs must get 2000 calories a day. If he will consume food in an amount, equivalent only to 1500 calories a day, then in a week he will become thin approximately on 500 gs. If he consumes only 1000 calories a day, the slimming will make the whole kilogram for a week. Except for the special circumstances, to lose weight more than on 1-1,2 kg a week is undesirable. Moreover, although for most people the loss of a few kilograms threatens nothing; it is possible to begin the rapid decline of weight only under the doctor’s control.
As a rule, it is not recommended for children to reduce the weight. Best of all is to save the weight of an obese child at the permanent level, while a kid will not “grow” to it. When the question is about children’s obesity, it is important to remember that often it is related mainly to the insufficient physical activity, but not to the plenty of food and that it is simpler and more effective to increase the physical activity of a child, than to limit him in the meal. It will be necessary also to mean, that the permanent critical remarks concerning the obesity of a child or teenager bring more harm, than benefit. Finally, it is necessary to emphasize that any kind of diet for growing children must be valuable. The use of the unbalanced fashionable diets, even if they provide the decline of weight, may have very heavy consequences.
An important value in controlling of body weight is the attitude of the man and surroundings. Although the fight against obesity requires the self-discipline and persistence, it mainly presents a medical, but not moral variation of problem, and doctors, as well as all the surroundings, must help a patient, but not to convert obesity into the cause for reproaches.
Frightening is not certainly recommended, however the underlining of connection between the obesity and illnesses, and also positive influence of decline of weight on the appearance often serves as an incentive reason for the patient. Nevertheless the promises of rapid success may appear so dangerous, as well as threats, in particular when the question is about children.
Experience shows that most people imagine very dimly, what foods are high-calorific, and what are not. Therefore a doctor must make sure that a patient has some picture of power value of different foods of feed. Advertising of producers, propagandizing low-caloric bread, light beer etc interferes a complete awareness in this area. A popular information about the effect of physical exercises also requires corrections. It is quite not needed for the obeses to exhaust themselves from time to time by the excessive loading. However they must firmly know that the course of slimming requires the everyday moderate physical activity, if only, that is extremely rarely, it is not contra-indicated on the medical considering. it is necessary to lead to the patient the role of genetic predisposition to obesity, for the persons with the “burdened” heredity to watch especially carefully after the weight.
The value of physical activity for the fight against an overweight is often neglected, and such approach is even ridiculed sometimes. It is related to two erroneous presentations. One of them consists in that most physical loading is allegedly attended only with very small power inputs, and the second is in that the increase of physical activity allegedly is always accompanied by the increase of consumption of food, that deletes its effect. The first error is easy to overcome, familiarizing with the concrete table of power expenses at the various types of physical activity. For an hour of walking, for example, a man weighing about 70 kg depending on the fast spends from 150 to 400 calories over ordinary. While running the same man expends from 800 to 1000 calories in an hour, while wheeling – from 200 to 600, and while rowing – to 1200 calories in an hour. Moreover, an obese man expends more energy on the same type of physical activity, than the man of normal weight.
The second misbelief according to which the increase of physical activity entails the increase of use of food is based on the misinterpretation of the known facts. Really, the additional loading for a physically active man requires a corresponding increase of calorie intakes, otherwise the progressing exhaustion develops, and death may even come from malnutrition.
Farmers know since long ago, that maintenance of animals in close cages makes them more obese, and more data show that the similar factor – the full absence of physical activity – plays an important role in the development of obesity for a man. At the inspection of children, I mean schoolboys of initial and senior classes, who live near-by Boston, it was discovered that they usually acquire the superfluous weight in winter months, i.e. in the period, when the physical activity of most children in these climatic terms is mionectic. At comparison of class-mates of different weight, but of one height it turned out that the thick girls do not eat quite more than the girls of normal weight, and even less. However the thick girls spare far fewer time for the physical loading. Other interesting fact was found out at a survey and further analysis of motions of the thick and thin girls during the lessons of physical education. It turned out, that even during the lessons the first are not so active, as second ones.
Whenever possible (in absence of medical contra-indications) the persons suffering from obesity must regularly take exercises, especially children who can not be hold on strict diets, because it can tell on the height of the organism and have psychological fallouts. In addition, it is good to aspire to the harmonious development of child’s body, and not simply to the loss of fat.
The most accessible and inexpensive type of physical exercises is still walking. Although only 200-300 calories are spent for an additional sentinel walk, the daily expenses are added up. For a year, for example, the daily sentinel walks will provide the loss of such amount of calories, which is equivalent to 7-14 kg. Engaging in swimming and tennis will bring to the loss of approximately 700 calories for an hour. A healthy child does not test some unpleasant feeling from the half-hour of physical activity, requiring an expense of 500-600 calories in an hour.
The restrictive diets must answer three requirements: 1) to create the deficit of calories; 2) to provide the balanced feed in order to avoid health’s risk and 3) to be adapt, not very expensive and to correspond to the flavor of a patient, so that he with a pleasure could with some variations cleave to the chosen kind of diet for a long time, and may be, also during all his life. The widely advertised fashionable diets are able to provide the success for some short period, however they can not be recommended for the protracted period of time. An opinion was spoke out, that the special diets are possible to use for the reduction of sizes of stomach or diminishing
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