What should the states' obligations be, particularly in light of competing needs for limited resources? Mandatory screening adopted with public health rationale does not necessarily mean that everyone benefits from testing. Health care consumers, particularly those in areas using multiplayer systems of care, have widely differing levels of access to tests and interventions. Changes to one's health insurance can create substantial potential for harm if insurers refuse to pay for expenditures associated with a ''preexisting'' (genetic) condition, or impose premium increases that make treatments (even co-pays) unafford-able. Furthermore, the type of genetic test reporting can have devastating consequences. For example, California's newborn screening reporting requirements does not require reporting actual values, but rather only abnormal results. A recent case resulted in permanent injury because the actual values, which showed consistency for congenital hypothyroidism, were not reported. The physician received the results well after the critical point at which harm results if untreated. In court, the state was not held liable. In all cases, beneficence competes with other state demands. Particularly in areas of the world where the state imposes substantial restrictions on individual freedom, the state clearly cannot be relied on assuring ethical principles in practice.
Genomic medicine also challenges physician duties in the context of doctor-patient relationships. Physicians have a duty to protect a patient's confidentiality, but such is not absolute. Doctors are obligated to override patient confidentiality to report infectious disease, and warn people whom their patients have specifically threatened with violence. Whether genetic risks warrant similar exceptions, and if so, when, remains an important clinical concern, although several advisory committees have said that physicians may be permitted to breach confidentiality to warn third parties only as a last resort to avoid serious harm. A recent court case involved a daughter who sued her father's physician's estate for failure to warn her about her 50% risk of developing diffuse adenomatous polyposis coli. What ''serious'' harm is, though, is clearly different for different people depending on psychological factors and other situational factors.
There are other questions of physician obligations including, but not limited to, whether a physician is obligated to offer a genetic test, and if so, when and why? In the absence of appropriate indications and established standards of care, physicians have no special duty to offer a specific test. However, physicians have an ethical obligation to be knowledgeable about genetic disorders that occur with increased frequency in certain populations, such as sickle cell anemia in African-Americans, thalassemias in Mediterranean and Southeast Asian groups, and Tay-Sachs in the Ashkenazi Jewish population. Physicians have an ethical obligation to provide nondirective counseling in support of a patient's voluntary decision making.
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The use of dumbbells gives you a much more comprehensive strengthening effect because the workout engages your stabilizer muscles, in addition to the muscle you may be pin-pointing. Without all of the belts and artificial stabilizers of a machine, you also engage your core muscles, which are your body's natural stabilizers.