Permanent Vascular Access For Hemodialysis Health And Social Care Essay

Permanent Vascular Access For Hemodialysis Health And Social Care Essay Introduction: A progressive rise in the number of patients accepted for renal replacement therapy has been reported world wide . Permanent vascular access (VA) is the life-line for the majority of these patients, when hemodialysis is the treatment of choice. Thus, the successful creation of permanent vascular access and the appropriate management to decrease the complications is mandatory. A well functional access is also vital in order to deliver adequate hemodialysis therapy in end stage renal disease (ESRD) patients. Unfortunately, despite the advances in hemodialysis technology, in the field of vascular access in the last years the introduction of the polytetrafluoroethylene (PTFE) graft and the cuffed double lumen silicone catheter were the only changes. But the cost of vascular access related care was found to be more than fivefold higher for patients with arteriovenous graft (AVG) compared with patients with a functioning arteriovenous fistula (AVF) . It seems that the native arteriovenous fistula that Brescia and Cimino described in 1966 still remains the first choice VA . Thereafter, vascular access still remains the Achilles heel of the procedure and hemodialysis vascular access dysfunction is one of the most important causes of morbidity in this population . It has been estimated that vascular access dysfunction is responsible for 20% of all hospitalizations and the annual cost of placing and looking after dialysis vascular access in the United States exceeds 1 billion dollars per year . Nowadays, three types of permanent vascular access are used: arteriovenous fistula (AVF), arteriovenous grafts (AVG) and cuffed central venous catheters. They all have to be able to provide enough blood flow in order to deliver adequate hemodialysis, have a long use-life and low rate of complications. The native forearm arteriovenous fistulas (AVF) have the longest survival and require the fewest interventions. For this reason the forearm AV, is the first choice, fol lowing by the upper-arm AVF, the arteriovenous graft (AVG) and the cuffed central venous catheter as a final step . History of vascular access Vascular access for hemodialysis is closely associated with the history of dialysis. Glass needles were employed as vascular access when hemodialysis came into view in 1924. The first haemodialysis treatment in humans was carried out by Haas G who used glass cannulae to acquire blood from the radial artery and reverting it to the cubital vein . Venipuncture needles were used as means for blood acquisition from the femoral artery and its reinfusion to patient by vein puncture, in 1943 by Kolff W. . Regular hemodialysis treatments were possible in 1950s through the use of a medical apparatus ( Kolff s twin-coil kidney ), thus projecting the problem of a reliable, capable of repeated use vascular access. Today, the artery-side-to-vein-end-anastomosis has become a standard procedure . In 1952, Aubaniac had described the puncture of the subclavian vein . In the 60s, by using Alwalls experience, Quinton, Dillard and Scribner developed arteriovenous Teflon shunt . This procedure involved two thin-walled Teflon cannulas with tapered ends were inserted near the wrist in the forearm, one into the radial artery and the other into the adjacent cephalic vein. The external ends were connected by a curved Teflon bypass tube. Later, the Teflon tube was replaced by flexible silicon rubber tubing. After the advancement of permanent vascular access, the possibility of maintenance hemodialysis was a fact and therefore a groundbreaking procedure. In the subsequent years many variants of the AV shunt were used, with the majority of them concerning temporary vascular access from the onset of chronic dialysis treatment compensating for the time of AV fistulas absence or maturity. In 1961, Shaldon performed hemodialysis procedures by inserting catheters into femoral artery and vein, using the Seldinger-technique . Over time, vessels in different sites were used, including the subclavian vein jugular and femoral. In 1962 Cimino and Brescia described a simple venipuncture for hemodialysis . In 1963 Thomas J. Fogarty invented an intravascular catheter with an inflatable balloon at its distal tip designed for embolectomy and thrombectomy . The first surgically created fistula was placed in 1965, followed by further 14 operations in 1966. In 1966 Brescia, Cimino, Appel and Hurwich published their paper about arteriovenous fistula. Appell had performed a side-to-side-anastomosis between the radial artery and the cephalic antebrachial vein. One year later, in 1967, M. Sperling reported the successful creation of an end-to-end-anastomosis between the radial artery and the cephalic antebrachial vein in the forearm of 15 patients using a stapler . In the next few years this type of AV anastomosis received popular approval. However this procedure was cast aside as first choice AV, due to the increasing numbers of elderly, hypertensive and diabetic patients with demanding vessels and high risk of a stea l syndrome. End-to-end-anastomoses are still a common place technique in revision procedures. In 1968 Rà ¶hl L. published thirty radial-artery-side-to-vein-end anastomoses . After anastomosis was performed, the radial artery was ligated distal to the anastomosis, thus resulting in a functional end-to end-anastomosis. Today, the artery-side-to-vein-end-anastomosis has become a standard procedure . In 1970, Girardet R. and Brittinger W.D. described their experience with the femoral vein and artery for chronic hemodialysis. Experimental trials have been done by several authors in order to establish a permanent vascular access using subcutaneous tunnel. Brittinger W. was the first to implant a plastic valve as a vascular access in an animal model but unfortunately his efforts did not proceed to a human one . Moreover during the early 70s, Buselmeier T.J. developed a U-shaped silastic prosthetic AV shunt with either one or two Teflon plugged outlets which communicated to the outside of the body. The U-shaped portion could be totally or partially implanted subcutaneously . Subsequ ently pediatric hemodialysis patients were extremely favored by this procedure. New materials for AV grafts were presented in 1972, one biologic and two synthetic.. In 1976, L.D. Baker Jr. presented the first results with expanded PTFE grafts in 72 haemodialysis patients . In the years to come several publications indicated the benefits and the shortcomings of the prosthetic material in question remaining the primary choice of graft for hemodialysis VA to date. The same year two authors, Mindich B. and Dardik H. had worked with a new graft material: the human umbilical cord vein. . Regrettably so, this material did not succeed in becoming a revolutionary graft material due to its inadequate resistance against the trauma of repeated cannulation and their complication (aneurysm and infection). After the subclavian route for haemodialysis access was firstly introduced by Shaldon in 1961, it was further processed in 1969 by Josef Erben, using the intraclavicular route . In the next 20 y ears or so, the subclavian vein was the preferred access for temporary vascular access by central venous catheterization. Today, due to phlebographic studies revealing a 50% stenosis or occlusion rate at the cannulation site, subclavian route has been discarded. The subclavian stenosis and occlusion predispose to oedema of the arm, especially after creation of an AV fistula . The first angioplasty described by Dotter et al who introduced a type of balloon, was immensely conducive to the resolution of one of the most significant predicaments in vascular surgery and vascular access surgery . In 1977 Gracz K.C. et al created the proximal forearm fistula for maintenance hemodialysis, a variant of an AV anastomosis . An adjustment of this AVF became quite significant in the old, hypertensive and diabetic patients on the grounds that it allows s a proximal anastomosis with a low risk of hypercirculation . In 1979 Golding A.L. et al developed a carbon transcutaneous hemodialysis access device (CATD), commonly known as button, as a blood access not requiring needle puncture . As a procedure of third choice, these devices were expensive and never gained widespread acceptance. Shapiro F.L. described another type of A.L. button, a device similar to that developed by Golding . Angioaccess classification Years after the initial efforts to create the appropriate vascular access in order to perform a safe hemodialysis, modern Nephrologists have now the possibility to select the appropriate access for their patients. So the first distinction is made between temporary and permanent VA . Temporary VA with expected half-life less than 90 days, peripheral arteriovenous shunts and non cuffed double lumen catheters are included . Mid-term VA with expected half life in 3 months to 3 years include veno-venous accesses (tunneled cuffed catheters and port catheter devices) and arteriovenous internal shunts, requiring vascular graft synthetic (PTFE) or biologic (saphenous vein, Procol, etc.) material ,or external shunt. Long-term VA with an expected half-life more than 3 years includes virtually the native arteriovenous fistulas and the new generation of PTFE grafts . Acute hemodialysis vascular access They are used for urgent hemodialysis and should be easy to insert and available for immediate use. Currently there are available two types of such accesses: Non-tunneled dialysis catheters and cuffed, tunnelled dialysis catheters. Double-lumen, non-cuffed, non-tunnelled hemodialysis catheters are the preferred method for immediate hemodialysis when a long term access is not available. They are made of polymers which are rigid at room temperature to facilitate insertion but soften at body temperature to minimize vessel injury and blood vessel laceration. The proximal and distal lumens should be separated by at least 2 cm to minimize recirculation . These catheters can be inserted into the central veins: femoral, jugular, or subclavian veins . The femoral artery can be used as an access central vein when all others central veins have been excluded. A modified Seldinger guide wire technique is used for their insertion. Image guided assistance in placing these catheters is recommended to avoid or minimize some of the immediate insertion complications, but non-cuffed catheters are also suitable for use at the bedside of the patient The 2006 National Kidney Foundation Dialysis Outcomes Quality Initiative (K/DOQI) guidelines recommend, after internal jugular or subclavian vein insertion, identifying radiographically any potential complications and confirming tip placement prior to either anticoagulation or catheter use . These guidelines also recommend ultrasound vessel identification prior to insertion. In general, now the subclavian catheters should be avoided because of the high incidence of vein stenosis and thrombosis. The maximum blood flow with this class of catheters is usually blood pump speeds of 300 mL/min, with an actual blood flow of 250 mL/min or less . Femoral catheters have to be at least 18 to 25 cm in length in order to have lower recirculation. The routine use-life of these catheters varies by site of insertion. In general, internal jugular catheters are suitable for two to three weeks of use, while femoral catheters are usually used for a single treatment (ambulatory patients) or for three to seven days in bed bound patients . However, the KDOQI guidelines suggest that non-cuffed, non-tunnelled catheters be used for less than one week and that cuffed, tunnelled catheters be placed for those who require dialysis for longer than one week . More recently a non-cuffed, non-tunnelled triple-lumen dialysis catheter has been developed. The purpose for third lumen is for blood drawing and the intravenous administration of drugs and fluid. In a multicenter, prospective study, blood flow rates and infectious complications were similar with double lumen catheter . Infectious complications are the principal reason why the catheter must be removed. Permanent Vascular Access Taking into consideration patient factors such as life expectancy, comorbidities, and status of the venous and arterial vascular system is very important in order to prescribe the appropriate access. Other factors are determined by the type of access itself, as arteriovenous fistula (AVF), arteriovenous graft (AVG), or TC which have a different effect on circulatory system. Also the duration of their functionality and the risk for infection and thrombosis are important factors to consider. Each type of surgical anastomosis has advantages and disadvantages . In 2002 the American Association for Vascular Surgery and the Society for Vascular Surgery published reporting standards according to which three essential components of VA should be mentioned: conduit (autogenous, prosthetic), location and configuration (strait, looped, direct, etc.) . Arteriovenous fistula An AVF is the preferred type of vascular access; it has the lowest complication rates for thrombosis (~ one-sixth of AVGs) and infection (~ one-tenth of AVGs) . There are 3 types of AVF s: à ¢Ã¢â€š ¬Ã‚ ¢ First type when artery and vein are connected in their natural position, either with a side-to-side or a side-artery-to-vein-end anastomosis. à ¢Ã¢â€š ¬Ã‚ ¢ Second type, where a vein is moved to connect to an artery in end-to-side fashion to either bridge a larger anatomical distance, or to bring the vein to the surface where it is accessible for cannulation and requires a tunnel to position the vein in its new location. à ¢Ã¢â€š ¬Ã‚ ¢ Third type where a vein is removed from its anatomical location and, is connected to an artery and vein in end-to-end fashion. Both second and third type requires the formation of a tunnel . End-to-end anastomoses are now rarely performed, since the complete disruption of the artery imposes a risk for peripheral ischemia and thrombosis. The most common surgical technique today is the side-to-end anastomosis. However technical problems as cutting the end of the vein in an oblique angle may create functional problems due to stenosis. An anastomosis more proximal in the arterial system should be smaller to prevent steal and limit maximal fistula flow, with the inherent complication of ischemic steal or heart failure . Arteriovenous fistula creation is often performed under local anaesthesia, with low morbidity and requires time for maturation. Data from the Dialysis Outcomes and Practice Patterns Study (DOPPS) indicate that AVFs should mature at least 14 days before use . Fistula size and flow increase over time, of 8-12 weeks and the initial blood flow rates has a range of 200-300 mL/min. Placement of AVFs should be initiated when the patient reaches CKD stage 4, or within 1 year of the anticipated start of dialysis. A physical examination should document blood pressure differences between the upper extremities and an Allen test should be performed, the lack of a well-developed palmar arch predicts a higher risk for vascular steal symptoms if the dominant artery is used for forearm fistulas creation due to inadequate collateral circulation . Ultrasound must be done before surgical implantation because it can provide information for maximal surgical success by mapping arteries and veins; eg, a preoperative arterial lumen diameter >2 mm is associated with successful fistula maturation, while a diameter of 600 mL/min, a diameter >0.6 cm with discernible margins, and be at a depth of 0.6 cm (between 0.5 and 1.0 cm) from the surface 6 weeks after creation. In fistulas that are maturing successfully, flow increases rapidly post-surgery, from baseline values of 30-50 mL/min to 200-800 mL/min within 1 week, generally reaching flows >480 mL/min at 8 weeks .The AVFs must be evaluated 4-6 weeks after placement, and experienced examiners (eg, dialysis nurses) can identify non-maturing fistulas with 80% accuracy . Arteriovenous graft AVGs were the most commonly used type of dialysis access in the US however, they do not last as long as AVFs and have higher rates of infection and thrombosis . Grafts present a second choice of VA when AVF are not able to be performed because of vascular problems. They can be placed in the forearm, the upper arm, and the thigh, and can have a straight, curved, or loop configuration. They may offer a large surface area for cannulation. AVGs can be cannulated about 2-3 weeks after placement, although there are studies suggesting that immediate assessment after placement for PTFE AVGs is possible . This interval is needed in order to allow the surrounding tissue to adhere to the PTFE conduit, to reduce the postsurgical oedema and the risk for local complications such as perigraft hematoma and seroma . Tunnelled hemodialysis catheter TCs are used when AVFs or AVGs arent possible to be created for several reasons such as multiple vascular surgeries, that lead to vascular thrombosis or when patients have severe peripheral vascular disease or very low cardiac output. Its more often in paediatric and very old patients. Unfortunately they are associated with the highest infection rate and they are not a very long-term access option. Studies have revealed that central venous catheters are colonized within 10 days of placement; however, colonization of the catheter biofilm does not correspond to positive blood cultures or clinical signs of bacteremia . Recently Power A. et al published their experience with 759 TCs. The survival rate at 1,2 and 5 years was 85%, 72% and 48% respectively. The infection rate was 0.34 per 1000 catheter day showing with careful and appropriate use of TCs, they can provide effective and adequate long term hemodialysis and rates of access related infection almost similar to AVGs . Hemodialysis vascular access in children The choice of replacement therapy in children is variable. The registry of the North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) reports that of patients initiating renal replacement therapy in paediatric centres : one quarter of children underwent preemptive renal transplantation, one half were started on peritoneal dialysis and one quarter were started on hemodialysis. Kidney transplantation remains the preferred therapy for paediatric patients therefore, many paediatric patients receive maintenance HD through an indwelling catheter in perspective of short HD period . In the United States less than 800 paediatric patients receive maintenance HD therapy, therefore surgical experience and clinical data for fistulae or grafts creation in small patients is limited due to rare need for such procedures. Smaller patients, especially those less than 10kg, are very demanding in surgical and nursing skill, this is significant reason the majority of smaller patients re ceive PD for their maintenance dialysis modality . Peritoneal dialysis is much more common in infants and younger children , significantly due to problems of vascular access. However, hemodialysis can be performed successfully in infants and very young children, as well . Children who will join in hemodialysis will need evaluation of their vasculature for placement of an arteriovenous (AV) fistula, arteriovenous graft, or cuffed double lumen catheter. The use of an AV fistula, the recommended type of vascular access in adults, is limited in children due to the size of their vessels. In the 2008 NAPRTCS annual report, vascular access for hemodialysis included external percutaneous catheter in 77.7 percent of patients, internal AV fistula in 12.3 percent, and internal and external AV shunt in 7.3 and 0.7 percent, respectively . K/DOQI has encouraged greater use of AV fistulas in larger children receiving hemodialysis who are not likely to receive a transplant within 12 months, with a goal of achieving more effective dialysis with fewer complications (eg, infection) than occurs with catheters. The choice of catheter size and configuration depends on the size of the patient. It is suggested by studies that in children as small as 4 to 5 kg a dual-lumen 8 Fr catheter can be well tolerated, and as the child becomes larger in size, a larger volume access can be placed . Vascular access should be able to provide sufficient blood flow and adequate dialysis with a Kt/V greater than 1.2. Kt/V is influenced further by the recirculation rate. Because flow rates in paediatrics vary by the size of catheter, which varies by the size of the patient, a recommended flow rate of 3 to 5 mL/kg/min is acceptable in most patients . Vascular access complications and Survival Studies have shown a mortality risk dependent on access type, with the highest risk associated with central venous dialysis catheters, followed by AVGs and then AVFs . The CHOICE study examined mortality based on access type in 616 hemodialysis patients for up to 3 years of follow-up. Central venous catheters and AVGs were associated with approximately 50% and 26% increased mortality, respectively, compared with AVFs with prevalence in men and elderly patients . Despite these findings and the KDOQI recommendations, dialysis access data from 2002-2003 showed that only 33% of prevalent hemodialysis patients in the US were being dialyzed via AVFs. Contrary in Europe and Canada, the majority of the patients (74% and 53% respectively) were being dialyzed via AVFs . Vascular access admissions continue to fall, with more procedures now performed in an outpatient setting, and are 45.1 percent below levels noted in 1993. By two-year time period, the adjusted relative risks of all- cause and cardiovascular hospitalization among hemodialysis patients vary little when compared to the reference period of 1997-1998; the risk of hospitalization for infection, however, is now 18 percent greater than in the reference period, while that of a vascular access hospitalization is 30 percent less. Among African American patients, the relative risk of an all-cause hospitalization or one related to infection is almost equal to that of white patients; the risk of a vascular access hospitalization, however, is 24 percent higher. In our previous work with 149 hemodialysis patients who had undergone 202 vascular access procedures (177 Cimino-Brescia fistulae and 25 PTFE grafts we found that the Cimino-Brescia fistula was used as the first choice of vascular access in all patients except one in the elderly group. PTFE grafts were the second or third choice in 7 patients younger than 65 and 15 in the elderly group (p: NS). The only reason for technique failure was vascular thrombosis in both groups (p: NS). Other complications were: aneurysms (10/48 and 14/101, p: NS), infections (0/48 and 2/101 p: NS) and oedema (0/48 and 6/101, p: NS). (Table à ¢Ã¢â€š ¬Ã‚ ¦.. Five-year technique survival of the first AV fistula in the two groups was 35% and 45% respectively (log-rank test, p: NS). (FIGUREà ¢Ã¢â€š ¬Ã‚ ¦..) Our findings suggested that there was no difference in vascular access complications across age groups and the survival of the first AV fistula is independent of age. Other encouraging results include a 22.9 percent fall in dialysis access admissions since 1999 for peritoneal dialysis patients, among hemodialysis patients, admissions for bacteremia/septicemia continue to rise sharply, reaching 112 per 1,000 patient years similar to the rate of 109 for vascular access infections, and possibly reflecting an increased use of cuffed catheters. In 2010 USRDS Annual Data Report hospitalization in 2008, increased again, to a point 45.8 percent above their 1993 level. In 2007-2008, women treated with hemodialysis were 16 percent more likely to be hospitalized, overall, than male. They also had a greater risk than men of cardiovascular, infectious, and vascular access hospitalizations 11, 14, and 29 percent greater, respectively. Recently unpublished our data are more different than those we published in 1998. We found in 189 patients that female had more possibility to start HD with double lumen catheter than male and also patients with heart failure ind ependent of sex. Female patients had PTEF grafts as first vascular access (p=0,023) and the elderly patients had more complications and more vascular access procedures (p=0.026). Non-tunnelled double lumen catheters complications The non-tunnelled double lumen catheters complications concern the insertion, the infection and thrombosis of the vessel. The severity and likelihood of insertion complications varies with the site of insertion. The complication rate and the severity are lowest in the femoral position. The primary problem is perforation of the femoral artery. Bleeding usually resolves within minutes of direct compression. Large femoral or retroperitoneal hematomas occur occasionally . Subclavian insertion complications are potentially more serious. Over-insertion of guide-wire can occasionally lead to atrial or ventricular arrhythmias. The vast majority of these are transient and hemodynamically insignificant . Penetration or cannulation of the subclavian artery can lead to hemothorax, which in some cases requires a thoracotomy tube. Cases of pericardial rupture and tamponade also have been described . Subclavian insertion from the left has an increased risk of atrial perforation which can present with acute hemopericardium upon initiation of dialysis. The incidence of pneumothorax varies from less than 1 percent to mor e than 10 percent of insertions, depending on the skill and experience of the physician. The risk of pneumothorax is greater from the left than right side, since the pleura and dome of the lung are higher on the left . Due to high rate of catheter-induced subclavian stenosis and subsequent loss of the ipsilateral arm for future hemodialysis access internal jugular vein insertion, particularly the right internal jugular vein is the preferred site of insertion. At internal jugular insertions carry a higher likelihood of carotid artery penetration, but a lower risk of pneumothorax (0.1 percent). Ultrasound guided cannulation of the vessel is recommended to minimize these complications. The location of the catheter tip in subclavian and internal jugular insertion should always be confirmed by fluoroscopy or x-ray prior to the initiation of hemodialysis or the administration of anticoagulants. Ultrasound-guided catheter insertion is lesser likelihood of arterial puncture or pneumothorax . Prevention and treatment of catheter thrombosis are important clinical issues. To prevent formation of thrombus, both lumens of the double lumen catheter are instilled with heparin following hemodialysis. The amount injected should only fill the catheter lumen to minimize systemic heparinization. Anecdotal evidence suggest that chronic anticoagulation with warfarin or low molecular weight heparin may also prevent catheter thrombus, due to either intraluminal clot or fibrin sheath formation . Lytic agents such as urokinase and alteplase are effective in treatment of catheter thrombosis. Alteplase has effectiveness rates in thrombosis treatment comparable to that observed with urokinase . However if non-cuffed catheters cannot have adequate blood flow then they should be exchanged. Ventral vein catheters are associated with the development of central vein stenosis . This complication appear s to occur more often with subclavian (40 to 50 percent of cases in some studies) than with internal jugular insertions (up to 10 percent) . It has been proposed that central venous cannulation creates a nidus of vascular injury and fibrosis. The rapid blood flows associated with the hemodialysis catheter then create turbulence that can accelerate endothelial proliferation, eventually leading to venous stenosis . The K/DOQI guidelines therefore recommend avoiding placement in the subclavian vein, unless no other options are available. If central venous thrombosis is detected early, it responds well to directly applied thrombolytic therapy or to percutaneous transluminal angioplasty when the fibrotic stenosis can be crossed with a guidewire . The infection risks associated with temporary double lumen catheters include local exit site infection and systemic bacteremia, both of which require prompt removal of the catheter and appropriate intravenous antibiotic therapy . Bacteremia gene rally results from either contamination of the catheter lumen or migration of bacteria from the skin through the entry site, down the hemodialysis catheter into the blood stream . Skin flora, Staphylococcus and Streptococcus species, are responsible for the majority of infections. There is conflicting evidence concerning the risk of infection based upon the site of insertion. In the largest prospective randomized study, the risk of infection was not reduced with jugular versus femoral venous catheterization . A prospective nonrandomized studies suggest that the infection risk appears to sequentially increase for hemodialysis catheters inserted into the subclavian, internal jugular, and femoral veins, respectively . Overall, compared with the subclavian vein, the internal jugular vein remains the preferred access site in ambulatory patients because of the high rate of central vein stenosis associated with subclavian vein catheterization (see above). In the Intensive Care Unit, either femoral or internal jugular vein placement is satisfactory, with the use of ultrasound making internal jugular vein placement safer. The best solution is to prevent the infection by proper placement technique, optimal exit site care and management of the catheter within the HD facility . Arteriovenous fistulas complications Complications of AVFs can be divided into early and late causes. Early causes include inflow problems such as small or atherosclerotic arteries, or juxta-anastomotic stenosis so a pre-operative evaluations for suitable access sites has to been performed . The aetiology of this acquired lesion is not entirely clear, but may be related to manipulating the free end of the vein, torsion, poor angulation, or loss of the vasa vasorum during anatomic dissection. This lesion often can be adequately treated with angioplasty or by surgical revision . Outflow problems may include accessory veins that divert blood flow from the intended superficial vessel to deeper conduits, or central venous stenosis in patients with prior central venous catheters. Vessels smaller than one-fourth of the fistula diameter are usually not hemodynamically relevant. Juxta-anastomotic stenosis and accessory veins are the most common causes for early failure AVFs when pre-operative evaluations for suitable access sites have been performed . Late causes for failure of AVFs include venous stenosis, thrombosis, and acquired arterial lesions such as aneurysms or stenosis. Venous stenosis may become apparent as flow decreases over time, worsening weekly Kt/V ([dialyzer clearance _ time]/body volume) or increasing recirculation. Native fistulas typically will not thrombose until flow is severely diminished. Static pressure measurements, which are helpful in graft monitoring, do not appear as helpful in AVFs, since collaterals surrounding the stenosis area often develop, effectively masking the rise in fistula outflow resistance. Stenotic lesions can be treated by angioplasty. Thrombectomy of fistulas, although technically more challenging than in AVGs, is often successful and if flow is re-established, primary patency is longer than in grafts . Aneurysms may form over the course of years as the fistula increases with increased flow and, unless associated with stenotic lesions, are more a cosmetic than functional concern. If the skin overlying the aneurysm is blanching or atrophic, or if there are signs of ulceration

Law and Crown Colony Essay

1. The two other reasons why Spain claimes the country as its possession or ghe property of the King of Spain. †¢ They also claim the country because of their Spirit of Discovery to our country, improvements of their technologies (for travel and trading purposes) and acquisition of our territories †¢ being in actual possession of the philippines, it had the right to colonize it.In other words, Spain claimed the Philippines by right of dicovery and by right of actual occupation or conquest. 2. Crown colony * A crown colony also called a royal colony was a state that was under political control by Britain and that was ruled and governed by a Governor who had been appointed by the monarch through the secretary of state for colonies. Cayman Island is one example of present â€Å"crown colony 3. Because the governor-general himself has a widely range of own powers. He was also the King’s official representative in the colony. He possessed vast executive, legislative, and judicial powers. He issued orders with the force of law, which were called superior decrees. On the other hand, decrees or orders coming from the King of Spain were called Royal decrees or orders. 3. Why was the governor-general powerful? Enumerate his powers. * Because the governor-general himself has a widely range of own powers. He was also the King’s official representative in the colony. He possessed vast executive, legislative, and judicial powers. He issued orders with the force of law, which were called superior decrees. On the other hand, decrees or orders coming from the King of Spain were called Royal decrees or orders. 4. Define or explain the following a. Cumplase e. Capitan b. Audiencia f. Principalia c. Superior Decree g, Cabeza de Barangay d. Indulto de Comercio h. Ayuntamiento * A. Right of the governor to suspend the operation of a Royal decree or order relative in the Philippines if in his opinion, the sads order or decree would not be beneficial to the administration of the country.

Advertising Ethics: a Contextual Response Based on Classical Ethical Theory

Advertising Ethics: A Contextual Response Based on Classical Ethical Theory Cornelius B. Pratt E. LincolnJames ABSTRACT. F. P. Bishop argues that the ethical standard for advertising practitioners nmst be utilitarian. Indeed, the utilitarian theory of ethics in decision-making has traditionally been the preference of U. S. advertisingpractitioners. This article, therefore, argues that the U. S. advertising industry's de-emphasisof ;ontological ethics is a reason for its continuing struggle with unfavorable public perceptions of its ethics – and credibility.The perceptions of four scenarios on advertisingethics and the analyses of the openended responses of 174 members of the American Advertising Federation to those scenarios suggest that advertising practitioners need a stricter adherence to deontological ethics than is indicated in this study. Advertising, a traditionally high-profile management function since World War II, perpetuates a paradox. On the one hand, it is common ly touted by business and the academy as a major economic, social and competitive force in post-world war economies. On the other hand, it is, invariably, a bull's-eye for public wrath.Cowton (1992), Crisp (1987), and Litttechild (1982), for example, present evidence on consumer suspicion and antipathy toward and investor concerns about advertising Cornelius B. Pratt is Associate Professor in the Department of Advertising, at Michigan State University. His research has been published in suchjournals as the Journal of Media Planning, Journal of Business Ethics, Public Relations Review, Public RelationsJournal, Public Relations Quarterly, and Journalism Quarterly. E. LincolnJames is Associate Professorand Assistant Chairperson in tke Department of Advertising at Michigan State University.His work has appeared in several scholarlyjournals, including the International Journal of Advertising,Journal of Advertising, Journal of Direct Marketing, Journal of Media Planning, and Weberforschun g und Praxis. ethics. Such antipathy and concerns have a considerable history, having begun earlier in this century (Rogers, 1990). Since a national meeting of the Advertising Federation of America in March 1942, during which it created a 39-point code of ethics for advertising during World War II (The New York Times, 1942), U. S. ublics and regulatory agencies and businesses worldwide have had a consuming interest in ethics. In his widely acclaimed book,The Ethics of Advertising, Bishop (t949) argues that the ethicai standards of advertising should â€Å"meet the practical requirements of society at a given stage of development† (p. 88). Thus he suggests utilitarian, relativistic, not rigid, standards of ethics for the ad industry. In Nevett's (1985) rebuttal to Bishop's (1949) argument, he concluded: â€Å"The ethical case for advertising stands in need of rigorous re-examination† (p. 04). The industry is not oblivious to such a need; existing programs are being reva mped and others are being developed to respond to ethical issues. Indeed, selfregulation for socially responsible conduct has become an attractive option of industry associations as advertising practitioners report that their activities conform to the principles of business conduct, adopted March 2, 1984, by the Board of Directors of the American Advertising Federation (,~a~F)(Chonko et al. , 1987).This article re-examines advertising ethics and argues that the perfunctory adherence of the advertising industry to deontotogical ethics results in a public perception of the industry as more susceptible, on the average, to ethical dilemmas than are most other management functions. So pervasive is this perception that Bergerson (1991-1992), chairman of the Self-Regulation Committee of the AAF, criticized industry efforts that were largely directed at treating the symptoms of the problem rather than Journal of Business Ethics 13: 455–468, 1994.  © 1994 KluwerAcademic Publishers.P rinted in the Netherlands. 456 C. B. Pratt and E. L. James Greyser and Reece's (1971) update of the 1962 HBR study (Greyser, 1962) indicated that while business leaders had a continuing strong respect for the economic role of advertising, advertising standards had slipped in some areas from standards reported in 1962; and, advertising content, particularly its perceived truthfulness, drew major criticisms. More recent research underscores a rising tide of questionable practices and ethical problems among advertising practitioners (Carson et al. 1985; Hunt and Chonko, 1987; Nevett, 1985; Ossip, 1985; Rotzoll and Christians, 1980; Haefner, 1991).Consequently, Bergerson (1991–1992), for example, observes cynicism and indifference among the public toward advertising: â€Å"If the legislators, regulators and the public perceived advertisers to be more committed to legal and high ethical standards, their level of trust wilt rise and their level of unwelcome attention will fallâ₠¬  (p. 22). the problem itself. â€Å"Everyone in the industry should be interested in being a part of the solution,† Bergerson (1991-1992) wrote. The solution is to restore and maintain advertising's credibility† (p. 22). Purposes of study The purposes of this study are twofold. First, it examines AAF members' perceptions of four scenarios on advertising ethics, and analyzes their reasons for perceiving such scenarios as they did. Because members of the AAF — the largest association of advertising practitioners in the United States – operate in the trenches of the U. S. advertising industry, their perceptions could be typical of those in the industry.Based on their comments, the present study argues that deontological ethics be applied more readily to decision-making than is currently the case. Second, this study links practitioners' perceptions to ethical theories. Such a linkage is important because â€Å"(ethical) theories are like windows onto the w orld of moral reasoning. They are meant to provide vantage points from which important ethical decisions can be considered† (Lambeth, 1986, p. 25). The results of this study are, therefore, presented within the specific framework of classical theory: deontology.Theoretical framework: The classical ethical theory ofdeontology Advertising practitioners continually explore ethical systems that will guide their decision-making processes. Lambeth (1986) observes that such a â€Å"system of ethics cannot ignore the classical approaches of deontology and teleology, or the variants of them† (p. 28), and identifies the characteristics of such a system: A system of ethics must be flexible,but not so flexibleas to be a mere rationalization for the personal preferences of those who invoke it.In short, a systemmust have bite and give direction. Its precepts should offer continuity and stability, though not necessarilyinvariant outcomes. Rationale for study The growing literature on the morality of business practices indicates that, aside from greater semitivities to the environment and greater emphasis on a number of socially responsible actions, businesses, for the most part, still face ethical issues that were prevalent in the 1960s. The advertising profession, as business, is no less immune to the unsavory public perceptions of business ethics in general.Almost 30 years ago, while a Harvard Business Review (HBR ) survey of business leaders indicated great respect for and an improvement in the standards of advertising during 10 previous years, there was a greater tendency on the part of the leaders to think that a code of ethical pracnces was more desirable for advertising than it was for their own industries (Greyser, 1962). (p. 28) Kantian ethics, a time-honored classical ethical theory, provides the framework for discussing the implications of self-reported ethics for the advertising industry.Deontology is a duty-based, nonconsequentialist theory of ethic s that asserts that certain, human actions are inherently† right or wrong. (Eighteenth-century German philosopher Immanuel Kant (1724–1804) provided much of the moral reasoning for pure deontology. ) The emphasis is on the doer's actions. For example, it is always wrong to steal, lie or break a promise; it is one's moral duty to Advertising and ClassicalEtflical Theory tell the truth and to keep one's promises – regardless of the consequences.Universalizing an action is one criterion offered by Kant for determining the ethics of a decision or action. Does the decision, action, or advertising message treat people as ends or as means toward an end? Kantian ethics requires that the doer respect the rights, status and dignity of the people with whom she or he interacts. Deontology has a unique appeal to and major implications for the ethics of advertising practitioners. Consequently, the continuing search for clear-cut do's and don'ts is a major focus of a number of advertising departments, agencies, and associations.One worldwide approach to such a search is the adoption of an ethics code whose imperatives, with a deontological bent, require, for example, that â€Å"we will not knowingly create advertisement that contains false or misleading statement or exaggerations, visual or verbal† (American Association, 1990). Such self-regulation by codes of ethics is, therefore, one far-reaching measure the advertising industry has taken to address the everyday ethical questions that it confronts. Such a strategy contradicts Ekehind and Saurman's (1988) argument that such codes may not improve the professionalism of the practice.The rationale for such codes, argue advertising practitioners, is that the industry can distinguish right fi'om wrong. Beyond that, such self-regulation has the advantage of addressing headon some of the unfavorable public perceptions of advertising. The eight-item Advertising Principles of American Business, adopted Mar ch 2, 1984, by the American Advertising Federation Board of Directors, is replete with non-conditional, unequivocal â€Å"shalls† and â€Å"shall nots,† again, indicative of deontological requirements or proscriptions.Similarly, the Standards of Practice of the American Association of Advertising Agencies uses â€Å"musts† and â€Å"will nots† to disapprove unethical conduct among practitioners. These principles and standards satisfy both the principle of unity† and Kant's categorical imperative and reject the notion of situational ethics (Briggs and Bernal, 1992). Thus, theoretically, the advertising practice embraces non-conditional ethical requirements. A number of professional associations that seek self-regulation of advertising in the United States have adopted a number of codes of conduct to 57 which practitioners are expected to adhere, emphasizing, in essence, the importance of deontological ethics. Research questions This study poses three research questions: a What are AAF members' overall perceptions of advertising ethics as oudined in four scenarios on ethics? [] Do such perceptions vary significantly by the type of ethical issue confronted? a What are the implications of the classical theory† of deontology for the self-reported ethics of the sample practitioners?Method Questionnaire development A three-part questionnaire that had six statements on each of four potentially troublesome scenarios on moral issues was designed and pretested for clarity† and face validity on 20 respondents randomty selected from the relevant population. Responses to six statements on eachscenario were anchored on a four-point scale: 1 for â€Å"definitely yes,† 4 for â€Å"definitely no. † Respondents were requested 😠® comment briefly on their responses to the scenarios.The scenarios were developed by reviewing the standards of practice developed by three advertising associations: the 55,000-member AAF, the largest association of advertising professionals whose code of ethics was established in 1965; the American Association of Advertising Agencies, whose code was first adopted in 1924; and the National Advertising Division/ National Advertising Review Board, whose ethics code was created in 1971. The reviews identified issues of greatest ethical concern to the advertising industry.Additionally, the research literature on ethics in marketing and advertising was also examined for insights on formulating the scenarios. Hunt and Chonko (1987), for example, in extending an earlier study by Rotzoll and Christians (1980), identified six 458 C. B. Pratt and E. L. James Data collection major ethical problems from the responses of 269 advertising executives to an open-ended question: â€Å"Would you please briefly describe the aspect of advertising that poses the most difficult ethical or moral problem confronting you in your daily work? † (p. 19).Also, Wood et al. (1988) used 16 vig nettes to examine the ethics of business students and business professionals. Similarly, Bellizzi and Hite (1989), DeConinck and Good (1989), Dubinsky et al. (1991), Fraedrich and Ferrell (1992), and Mason et al. (1990) used scenarios, vignettes and statements to assess respondents' perceptions of ethics. Such hypothetical, ethics-related scenarios provide insights into business ethics, and have been found useful in replicating real-world situations for the purpose of evaluating moral conduct (DeConinck and Good, 1989; Dubinsky et al. 1991; Madden, 1989; Hegarty and Sims, 1979). A single-wave mail survey was used to collect data from the practitioner sample from the fall of 1991 through the winter of 1992. To encourage candid practitioner responses and to obtain an optimal response rate, a hand-typed, individually addressed covering letter, in which respondent's anonymity was assured, accompanied each questionnaire. A business-reply envelope was in each piece of mail. Respondents we re requested not to write any identifying information on the questionnaire. Results [email  protected]'le on respondents SamplingA systematic random sampling procedure was used to select names of AAF clubs and federations from the 1991 roster of the AAF. Following the receipt of notification that club participation in the survey had been approved, we mailed 2,010 copies of the questionnaire to executive directors or secretaries of clubs. Copies were distributed during general meetings of the clubs. Four hundred eighty-one of the 2,010 copies were returned in a single-wave mailing, yielding a 23. 9% response rate. Only 460 (22. 9%)were usable. This low response rate is consistent with those of similar studies (Akaah, 1990; Chonko et aI. 1987; Fritzsche and Becket, 1984; Greyser and Reece, 1971; Hunt et al. , 1984; Myers et al. , 1980; Randall and Gibson, 1990), which reported response rates between 17% and 31%. One hundred seventy-four respondents provided reasons for their respons es to all four scenarios, for an item-response rate of 37. 8%. Because one purpose of this study is to analyze respondents' reasons for their philosophical perceptions, the analyses of responses focus on those respondents who provided such comments. Table I presents a seven-item profile on the 174 respondents. The gender split was almost equal.About 4% of the respondents were 25 years or younger, 29% were between 26 and 34 years old and 34% between 35 and 43 years old. Eight percent and 5. 7% were in the 53-years-to-61-years and the 62years-or-older categories, respectively. Respondents represented each of 25 states in the United States. However, four states – California, Colorado, Illinois, Michigan – each had 10 or more open-ended responses. California, with 44 returns, had the most responses. More than one-half of the respondents had between one and 10 years of full-6me advertising experience, 26% between 11 and 20 years' experience, and 11% between 21 and 30 years' experience.About 1%had more than 40 years' experience. With regard to respondents' institutional affiliations, about 44% worked in an advertising agency or department, 17% in companies or corporations, 3. 4% in nonprofit organizations, and 32% in other organizations. About 35% of the respondents indicated that they were in top-management positions, for example, as owners, presidents, executive vice presidents, vice presidents, and directors. Twenty-six percent were categorized in upper-middle management positions: division heads, supervisors, managers.About 40% were categorized in lower-middle management positions, for example, as account executives, while 3%were categorized as non-management personnel. Advertising and Classical EtkicaI Theory TABLE I A demographic profile on respondents (N = 174), in percentages Gender Female Male States with 10 or more responses California Colorado Illinois Michigan 25. 3 6. 9 5. 7 10. 9 50. 6% 49. 4 459 While 24% of the respondents did not super vise any employees, a majority held supervisory positions. About 63% supervised between one and 10 eraployees, 7% between l l and 20, and about 3% more than 21 employees.Respondents' evaluation of and conmaents o n scenarios Scenario No. h (Giving gifts to a potential client) This scenario focused on a female ad person who gave gifts to a potential client with the intent of receiving assistance from the client in obtaining the latter's account. Slightly more than one-half of the respondents said that the ad person was wrong, t7% reported that she should be fired, 40% would do just what she did, while 56% said that most ad execs would do as she did. About 83% said their firms should address the situation formally in a policy.In this scenario, gift-giving perse was not an issue; however, the intent of that practice is important because one study (Hire and Beltizzi, 1987) indicated that gifts tend to obligate a client to a firm. Some respondents in the present study considered it a bri be. One, for example, wrote: â€Å"Any company I managed had a written policy on such matters. Mary would have been reprimanded orally and in writing. A copy would be placed in personnel file. This would contain a ‘warning. ‘ Next time, fired. † Another: â€Å"If it was an overt bribe it was wrong. If it was really a gift then no problem. A respondent who was blunt about the wrongness of the conduct defended its widespread occurrence in the industry: â€Å"What Mary did was wrong, but it is common practice in a more subtle way. † Perhaps reflecting the percentage of respondents who said that most ad executives would do what the ad person did, a number of respondents pointed out that the situation â€Å"happens quite frequently,† that it is â€Å"common practice,† that â€Å"‘gifts' is a highly ambiguous term,† that it is â€Å"standard in the industry,† that most account executives â€Å"routinely give away whatever they can to get business,† and that â€Å"romancing the client is part of business. Therefore, they think that nor much is wrong with it. In fact, most argued that it depended on the nature of the gift. Age 25 or younger 26–34 35–43 44–52 53–61 62 or older Years in full-time advertising 0 1-10 11-20 21-30 31-40 More than 40 years Work Setting Advertising agency/department Public relations agency/department Non-profit organization Company/corporation Other Management position Top management Upper-middle management Lower-middle management Number of employeessupervised 0 1-10 11-20 21-30 31-40 41-50 5t or higher 24. 1 62. 7 6. 9 2. 9 1. 7 1. 1 0. 6 34. 5 25. 8 39. 7 43. 7% 3. 4 3. 4 17. 2 32. 2 6. 52. 3 25. 9 10. 9 2. 9 1. 1 4. 0 29. 3 33. 9 19. 0 8. 0 5. 7 460 C. B. Pratt and E. L. James TABLE lI Responses to statements on ethics scenarios % yesa Mean u SD Statements on Scenario No. 1 (Giving gifts to a potential client) 1. What Mary- did was wrong. 2. Ma ry should be fired. 3. I would do just what Mary did. 4. Most ad execs would do just what Mary† did. 5. My firm/dept, has a policy, either written or oral, that addresses this situation or practice. 6. Regardless of mr† response to No. 5, it is a good idea for my firm/dept, to have a policy, either written or oral, that addresses the situation or practice.Statements on Scenario No. 2 (Lying about an update on an account) 1. What John did was wrong. 2. John should be fired. 3. I would do just what John did. 4. Most ad execs would do just what John did. 5. My firm/dept, has a policy-, either written or oral, that addresses this situation or practice. 6. Regardless of my response to No. 5, it is a good idea for my finrddept, to have a policy, either written or oral, that addresses the situation or practice. Statements on Scenario No. 3 (Seeking confidential information) 1. What Pete did was wrong. 2. Pete should be fired. 3. I would dojffst what Pete did. . Most ad execs wo uld do just what Pete did. 5. My firm/dept, has a policy, either written or oral, that addresses this situation or practice. 6. Regardless of my response to No. 5, it is a good idea for my firm/dept, to have a policy, either written or oral, that addresses the situation or practice. 63 18 40 47 22 2. 16 3. 35 2. 01 2. 43 3. 28 1. 14 0. 852 0. 961 0. 856 0. 917 59 18 57 78 24 2. 29 3. 43 2. 48 3. 00 3. 23 1. 05 55 17 40 56 31 2. 36 3. 40 2. 01 2. 62 2. 99 1. 18 0. 811 0. 982 0. 939 1. 15 83 1. 68 0. 918 0. 807 1. 03 0. 825 1,05 72 2. 04 1. 05 67 2. 12 1. 01Advertising and Classical Ethical Theoly Table)8 (Continued) %yes ~ Statements on Scenario No. 4 (Using outdated data) Mean b 46 t SD What Sally did was wrong. Sallyshould be fired. I would do just what Sally did. Most ad execs would dojust what Sally did. My firm/dept, has a policy, either written or oral, that addresses this situation or practice. 6. Regardless of my response to No. 5, it is a good idea for my firm/dept, to have a policy, either writtm. ~or oral, that addresses the situation or practice. I. 2. 3. 4. 5. 82 46 11 36 41 t . 62 2. 68 1. 51 2. 26 2. 84 0. 993 1. 07 0. 742 0. 9 t0 1. 12 81 1. 77 0. 39 a Percent responding â€Å"definitely yes† or â€Å"maybe yes. † b On a four-point scale, with 1 = â€Å"definitely yes† and 4 = â€Å"definitely no. † A lower mean score indicates a stronger agreement with a statement. Another, perhaps thinking situationally, asked: â€Å"Is it a pen, a ticket to a concert, or an automobile? † A president of an ad agency said: â€Å"Often, in this business, I encounter prospective clients that have been ‘wined and dined' by their previous agency. Some expert preferential treatment. The prospects that find this offensive and rely mostly on our agency's ethics, expertise and integrity are those we desire.This philosophy has lost us business, slowed our growth . . . . Business ethics unfortunately in the ad business is perceiv ed next to snake oil salesmen! † was wrong substantiated their positions with the following reasons: â€Å"There definitely are times when one must prioritize his/her workload . . . One should not lie to the client but instead talk openly about a schedule of completion and possibly see ifa delay would be acceptable. † D,- â€Å"Schedules for each project~client are developed on approval of estimates. All work is to be done per that schedule, regardless of dollars involved. â€Å"A company should try to meet a ctienCs deadlines no matter the size o f the account. † O n the other hand, some of those who felt nothing wrong had occurred said: ‘[john did tell the t r u t h . . . For John to tell the whole truth is simply suicidal. Agencies are always juggling workloads. † m,- â€Å"What John said was not a definite lie. As long as you do not directly tie about a scenario, don't worry. † m,- ‘[John did what most people would do, then work a li ttle harder to get the other work OUt. † &enario No. 2: (Lying about an update on an account)This scenario was on the failure o f an ad agency staffer to tell a client the truth about the status o f the client's account, which had been set aside temporarily in preference for a newer, higher-hilling account. Fifty-nine percent said that the ad agency staffer was wrong, 18% said that he should be fired, 57% reported that they would do just what he did, while 78% said that most ad execs would do what the staff did. About 72% said their agencies should address the situation in a policy. Some of those who argued that the agency staff â€Å"I see no reason to forfeit future business and, 462 C. B. Pratt and E. L. James herefore, would use whatever means necessary to maintain the relationship. † did. Eighty-one percent said that their agencies should address situation in a policy. Respondents were clearly angered by the ad executive's action. A respondent said: â€Å"This con duct is indefensible. The client paid for both the campaign and the research (I assume) and is entitled to their results. † â€Å"There should be truth in advertising and in all of life's encounters, business or personal. † Another: â€Å"Sally practiced deception in not using those current poll results. The client is bound to find out what sort of results the corporate image has, eventually. Yet another: â€Å"Bad judgment to cover up facts. Corrective measures to improve numbers in future campaigns should be provided to client. † Some arguments made in behalf of the ad executive: †¢ â€Å"They [the numbers] can be used as indicators, but not absolutes. How many people do you know that have participated in TV Nielsen rating surveys and how many programs have the networks cut or kept that you disagree with? † â€Å"What Sally did was not necessarily wrong or right, given the question. Possibly the campaign required more impact, time, etc. Too many v ariables in this situation to judge ethics. † â€Å"Numbers are arbitrary and research is imperfect.One set of ‘bad' numbers is, therefore, inconclusive. † &enario No. 3: (Seeking confidential information) During a social meeting, one ad account executive craftily encouraged another obviously inebriated ad executive who handled the account for a competing brand to divulge confidential business information. Sixty-three percent said that the ad account executive was wrong. Eighteen percent said that he should be fired, and 40% that they would do just what he did, while 47% said that most ad execs would do what the executive did. Sixty-seven percent said the ad agency should address the situation through policy-making.Among all four scenarios, scenario No. 3 had the second-highest disapproval rate among respondents. One respondent made a blunt, succinct comment: â€Å"A definite breach of professional ethics. † Another: â€Å"This is unacceptable as well as u nethical behavior. Once the account exec had identified himself, Pete should have identified himself as well. Pete should be reprimanded for his actions, maybe even fired if it appears as if this same scenario would continue in the future. † Another: â€Å"It was wrong not to identify himself. † Yet another: â€Å"Pete's taking advantage of his ‘counterpart' was opportunistic and immoral. A respondent who saw nothing devious here argued: â€Å"It is a very competitive market. Taking advantage of the competition's weakness or stupidity is a must. † Another argument: â€Å"Corporate espionage is no more or less right or wrong than is political espionage. † †¢ †¢ Comparison of means Scenario No. 4: (Using outdated data) In an agency's report to a client, a female ad executive used outdated data that were favorable to both her ad agency and client, while ignoring new, unfavorable information. Eighty-two percent – the highest among all s cenarios for statement No. – said that the female ad executive was wrong, 46% said that she should be fired, 11% that they would do just what she did, while 36% said that most ad execs would do what she Two analytical procedures were used to compute and compare responses to all four scenarios. First, the percentage response to each statement was computed for comparison of the directions of response patterns. Second, item-by-item statistical differences between 36 possible pairs of responses across all four scenarios were determined. Schefft's (1953) multiplecomparisons were used to determine such differences (Table III).Twenty-five of those 36 pairs and four of the six variable pairs of grand means were significantly different (p ;lt; 0. 05, at least) from each other, indicating respondents' differentiation of their evaluation of the scenarios. Thus, this result indicates Advertising and Classical Ethical Theory TABLE III Comparison of means, grand means (and standard deviati ons') for four scenarios on advertising ethics Scenario One 2. 3; (1. 18) 3. [email  protected] (0. 811) 2. 0P (0. 982) 2. 62~ (0. 939) 2. 99~ Scenario Two 2. 29~ (1. 05) 3. 4Y (0. 807) 2. 48b (1. 03) 3. 00b (0. 825) 3. 23b Scenario Three 2. 1; (1. 14) 3. 35~ (0. 852) 2. 0P (0. 61) 2. 43~ (0. 856) 3. 28b 463 Statement 1. What X did was wrong. 2. X should be fired. 3. I would do just what X did. 4. Most ad execs would do just what X did. 5. My firm/dept, has a policy, either written or oral, on situation or practice. 6. Regardless of my response to No. 5, it is a good idea for my firm/dept, to have a policy, either written or oral, on situation or practice. Grand Mean Scenario Four 1. 62b (0. 993) 2. 68b (1. 07) 1. 5V (0. 742) 2. 26d (0. 910) 2. 84~ (t. I 5) (1. 05) (0. 9! 7) (1. 12) 1. 68~ (0. 918) 2,63~ (0. 406) 2. 04b (1. 05) 2. 58~,b (0. 362) 2. 12b (1. 01) 2. 74c (0. 378) 1. 77~ (0. 39) 2. 52b (0. 401) ~,b. ~ Means with different superscripts on the same row are significantlyà ¢â‚¬  different, by ScheffS's repeated-measures design. Note: Means are on a four-point scale, with 1 for â€Å"definitely yes† and 4 for â€Å"definitely no. † Statements 3 and 4 were reverse-coded as t for â€Å"definitely no† and 4 for â€Å"definitely yes. † A lower mean score, therefore, indicated higher self-reported ethical standards. that the sample practidoners' perceptions of ethics vary significantly by the type o f ethical issue confronted, suggesting perceived differences in the intensity of the application of deontology to the scenarios.Fritzsche (1988) and Fritzsche and Becker (1984) reported similar differences across vignettes, and concluded that marketing managers practiced situational ethics. For three of the four scenarios, respondents tended to agree with the statement that the advertising staff involved in the conduct identified in each of the scenarios took the wrong action. However, they tended not to agree that the staff should b e fired. It was only in scenario No. 4 (using outdated data) that members tended to perceive the conduct as wrong; even so, the mean response to the statement that the staff â€Å"should be fired† was 2. 8, which was significantly different (p < 0. 001) from re- spondents' positions on the firing of the three other practitioners in the other three scenarios. Contextual response An overall evaluation of the respondents' evaluation of the wrongness or rightness of a conduct – the essence of Kantian ethics – indicates that the sample AAF members leave little doubt about their positions on the scenarios outlined in the questionnaire. However, when the evaluations of the statements, taken together, are considered within the context o f classical ethical theory, the members' ethics leaves much to be desired.Four questionnaire statements (items 1, 2, 3 and 6 of Tables II and III) were used as direct measures of deontology: â€Å"was wrong,† â€Å"should be f ired,† â€Å"I would 464 C. B. Pratt and E. L. James do,† and â€Å"regardless of my response. † It must be noted here that, even though deontology does not address explicitly the severity of the punishment for an ethical infraction, the theory is not neutral on punishment. Justice is one of the moral values that deontology considers – even though not always explicitly. In mixed-rule and mixed-act deontology, the consequences of one's actions are considered.In essence, there is a built-in role for consequences. This was why Kant, admittedly vague in some areas, invented moral rules in the first place. Responses to the four deontology-related statements provide four indications of the extent of practitioners' adherence to Kantian ethics. First, the respective percentages (28. 7%, 28%, 40% and 65%) of respondents who reported that the actions of the practitioners cited in the four scenarios were definitely wrong indicate that fewer than one-half applied deon tological theory to three of the four scenarios.Second, that the practitioner should be fired, the ultimate test of ethics (Singer, 1992), had much lower, definite approval rates: 1. 7%, 1. 1%, 3. 4%, and 16. 1%. Third, the response percentages for item 3 (â€Å"I would do just†¦ â€Å") in scenarios one, two, and three indicate that a sizable number of respondents would engage in the questionable behavior outlined in the scenarios. For scenario four, however, 11% said that they would â€Å"definitely† or â€Å"maybe† engage in a behavior that 82% of them reported as wrong.Finally, on item 6, a clear majority indicated an interest in organizational response to the issue raised in each scenario. The response percentages for statements 1, 2, and 3, therefore, indicate that practitioners' evaluations are clearly at odds with tile tenets of deontology and are perhaps more in line with utilitarian and relativistic theories. A further indication of the sample practiti oners' adherence to deontology is provided by those who responded â€Å"definitely yes† or â€Å"maybe yes† to all four measures of deontology in all four scenarios.The results: 10% 10%, 16%, 32% for scenarios 1, 2, 3, and 4, respectively. Such low percentages suggest that a majority of members wavered in applying deontology to the ethical dilemmas with which they were confronted. Bishop (1949) argues that truthtelling (addressed in scenarios 2 and 4) in advertising is â€Å"impossible and the attempt to attain it would reduce advertising to complete ineffectiveness and prevent it from fulfilling its legitimate and necessary function† (to. 88).Yet, the first of AAF's eight-principle code of ethics, albeit stated in general terms, focuses on truthtelting: â€Å"Advertising shall tell the truth, and shall reveal significant facts, the omission of which would mislead the public† (American Advertising Federation, 1984). While AAF members report that their com panies adhere to AAF principles, they report that other ad agencies tend to adhere less strictly to those principles (Chonko et al. , 1987). Adherence to the truth principle is not only evident among AAF members but it has the largest â€Å"my† versus â€Å"other† company difference ([t – 23. 2, p < 0. 01] Chonko et al. , 1987). A number of U. S. corporate executives now realize that if ethical transgressions are not sanctioned by dismissals, they could encourage all kinds of shady dealings and foster the perception that the organization is not really committed to ethics (Singer, 1992). It is plausible that a mix of utilitarian, JudeoChristian, veil-of-ignorance, and golden-mean ethics simultaneously guided the sample practitioners' evaluation of the ethical scenarios used in this stud),. However, the investigation of the application of various ethical theories to decision-making was not a purpose of this study.Empirical studies on ethics (e. g. , Ferrelt and Weaver, 1978; Fritzsche, 1988; Fritzsche and Becker, 1983; Krugman and Ferrell, 1981; Pratt, 1991; Pratt and McLaughlin, 1989) increasingly indicate that ethics among business people is frequently not perceived in absolutist terms, but in relative shades of right and wrong. Fritzsche (1991, 1988) and Jones (1991), for example, report that situational ethics is the overwhelming preference of U. S. managers. Advertising codes of ethics are usually written in precise deontological terms, for example, â€Å"must recognize,† â€Å"will not,† â€Å"shall tell the truth,† â€Å"shall refrain from. Yet, AAF members do not seem to abide by deontology even though â€Å"an enforced, effective code should provide the profession with a degree of stability and consistency in the ethical decision-making of its members† (Beets, 1991, p. 69). It is plausible that the patterns of responses in this present study suggest adherence to utilitarian ethics, which is preferred by advertising agency personnel Advertising and Classical Ethical Theory (Rotzotl and Christians, 1980; Christians et al. , 199 I). On the other hand, utilitarian ethics seeks to maximize the good for all concerned.However, the limitation of this ethical theory is inherent in how the â€Å"good† is determined. Beyond that, the interests of the minority tend to be given short shrift. What, therefore, are the chances that advertising-agency actions will result in the â€Å"greatest happiness for the greatest number†? Also, Nevett (1985) disagrees with Bishop's (1949) suggestion that the ethical standards of advertising be utilitarian because such an approach cannot â€Å"provide advertising people today with guidance on suitable ethical standards for their profession† (e. 04). Rawls (1971) criticizes utilitarianism, noting that it does not take seriously the differences among people; rather, it views as morally just that which has the sum of satisfactions (or tota l utility) for the community. As an alternative to utilitarian thought, Rawls (1971) suggests â€Å"a new moral theory† that will give adequate account to the primacy of justice, understood as the protection of the equal rights of all individuals, over the social good† (Schaefer, 1979, p. 22).To accomplish equal justice in society, therefore, everyone should assume a hypothetical â€Å"original position† – behind a â€Å"veil of ignorance† – which requires that, in evaluating situations, people step from their everyday, status-based traditional roles into an egalitarian position behind a veil. The goal is to develop a conception of justice or of the good from a disinterested, â€Å"equal† perspective. Would a recommendation that practitioners who compromise the ethical standards identified in the scenarios be fired be an illustration of such justice?And would such firing be in an organization's or in a society's best interest? Finally, it is plausible that Judeo-Christian morality – an altruistic, religion-based tradition – is also reflected in respondents' evaluations of the dilemmas in the ethical scenarios. 465 perceived as â€Å"definitely† having such policies for each of the four scenarios (and those who â€Å"definitely† think that having such policies is a good idea) are, respectively, 17. 8 (56. 3), 11. 5 (38. 5), 4. 6 (33. 3) and 15. s (50 0).The large differences between having such policies and thinking that having such policies is a good idea lends credence to the continuing public and practitioner concern over advertising ethics. For advertising agencies, such policies could result in two possibilities: (1) they may encourage agencies to also apply deontology to ethical issues, and (2) they may help agencies initiate an eclectic approach to ethical decision-making – that is, to apply ethical principles that may involve bringing all five commonly used classical theo ries to bear simultaneously on the decision-making process.These five theories, which are not mutually exclusive, fall into one of two broad categories: deontology or teleology. They are (1) Aristotle's golden mean (â€Å"moral virtue is appropriate location between two extremes†); (2) the theoretical framework for this present study, Kant's categorical imperative (â€Å"act on that maxim which you will to become a universal law†); (3) Mill's principle of utility (â€Å"seek the greatest happiness for the greatest number†); (4) Rawls's (1971) veil of ignorance (â€Å"justice emerges when negotiating without social differentiations†); and (5) Judeo-Christian persons as ends (â€Å"love they neighbor as yourself†).Aristotle's theory of the golden mean, a virtuebased ethics, strikes a moral balance between two extremes, one indicating excess, the other deficiency. The mean, in this context, is not a statistical mean but a willingness on the part of th e decision maker to exercise moderation or temperance – a virtue. Such a mean rdates to the individual's particular situation, her or his stay. is, strengths and weaknesses (Chi'istians et aI. , 1991). Utilitarian ethics, a form of teleological ethics, was enunciated by John Smart Mill as that which seeks â€Å"the greatest happiness for the greatest number. To assess the â€Å"greatest good,† a person or organization performs a cost-benefit analysis of an action or decision. If the latter would result in the good of the majority, that is, if its benefits for the â€Å"greatest number† outweigh its costs, then the act is ethically right. Rawls's (197 t) veil of ignorance, a nonconsequen- Conclusion The results presented in this study indicate a strong (perceived) reluctance on the part of the ad agencies to institute policies, either written or oral, that would proscribe unethical conduct. The percentages of respondents whose firms or departments are 466C. B. P ratt and E. L. James tialist theory of justice, governs the assignment of rights and duties and regulates the distribution of social and economic advantages. People, Rawts (197I) argued, â€Å"have an equal right to the most extensive basic liberty compatible with a similar liberty for others† (Rawls, 1971, p. 60). Finally, Judeo-Christian morality is an altruistic tradition that is being popularized in the West as â€Å"the more dramauc term agape – unselfish, otherregarding care and other-directed love, distinct from friendship, charity, benevolence, and other weaker notions† (Christians et al. 1991, p. 20). The interpretation of the results of this present study within the context of Kantian ethics suggests that deontology is clearly not the preference of the sample practitioners. The de-emphasis of deontological ethics among practitioners is likely to engender a laissez faire approach to ethical issues. Dubinsky et al. (1991) suggest a reason for this phenom enon from an overall business perspective: â€Å"Many of the situations business people confront are in a ‘gray' area where the delineation between the right versus the wrong action is not clear† (p. 52). On the other hand, strict deontologicaI ethics could encourage advertising practitioners to understand the precise boundaries of ethical and unethical conduct, as has been found among salespeople (Michaels et at. , 1988). It has been reported that managers who apply deontological ethics under uncertain conditions are least likely to change their decisions even when they perceive the risk of their decisions; those who apply utilitarian ethics are more likely to change their decisions to satisfy financial and/or self-esteem goals (Fraedrich and Ferrell, 1992).And herein lies a crucial value of deontological ethics to advertising: more likely, it will encourage advertisers to adhere to the precepts of ethics, setting aside personal financial and social rewards for the pub lic good. At least 67% of the respondents in the present study suggested that their organizations establish policies on questionable conduct (item 6). Why did such a majority suggest such boundaries on behavior? Why would they prefer that formal company policies restrict questionable behaviors?It is plausible that the sample practitioners place much value on formal policies because of the perceived importance of affirmation on what they consider ethical or unethical. Further, such a formal process may indicate more than a perfunctory commitment of their organizations to ethics. This possibility suggests two key questions on the implications of the results of the present study for policy-making: (1) Where lies the responsibility for shaping advertising agency ethics? (2) And what relevant does deontology have for the training of advertising staffs?In a speech given two dozen years ago by Bill Marsteller, founder of the advertising agency, Marsteller Inc. (a forerunner of Burson-Marst eller, the world's third-largest public relations agency), he said: â€Å"It is not enough [for the advertising student] to simply attain general standards of morality and taste; it is important to be subjected to the deliberate considerations of advertising morality and taste†¦ † (Marsteller, 1972, p. 241). Marsteller sees education in advertising ethics as important as that for the production of creative, charming advertising.Just as the effectiveness of training sessions has been called into question (Feldman and Thompson, 1990; Levin, 1989), their impact has also been demonstrated (e. g. , Feldman and Thompson, 1990; Hanson, 1987; Harris and Guffey, 1991). On balance, however, it behooves ad clubs and various advertising associations to establish programs that, at the minimum, sensitize practitioners to some of the social and professional sequelae of their ethics-related decisions. The results of this limited study justify the adoption of such measures.Caveats Two li mitations of this stud), should be outlined. The first is the old issue of â€Å"self-reported† ethics. Even though measures were taken to discourage the use of socially desirable responses, that possibility cannot be ignored because perceptual distoruon is higher when the dependent variable is as highly sensitive as the subject of ethics (Hunt et al. , 1989; Randall and Fernandes, 1991). The second is the representativeness of the sample, which was drawn from 25 states, for the 50,000member AAF.Because the sample was not randomly selected, it is important that this present study be replicated on a larger, more geographically diverse sample to determine the extent to which its results are consistent with those of such a nationwide study. Advertising and Classical Ethical Theory

President Theodore Roosevelt The President Of The United...

President Theodore Roosevelt was the 26th President of the United States of America. Roosevelt was an adaptive compliant President. He expressed great work ethic and leadership during his time in the White House. In fact while he was in office Roosevelt viewed the President as the â€Å"steward of the people† and kept that mindset all throughout his presidency. President Roosevelt in history is one of the youngest Presidents to assume the position of office. The start of Roosevelt’s Presidency started with the assassination of President William McKinley. President McKinley was shot by a man named Leon Czolgosz. Maybe if McKinley wouldn’t have died from these wounds Roosevelt may never have become one of the best presidents in U.S. history.†¦show more content†¦Many of these things that happened in Roosevelt’s childhood helped shape him for whom he would become as a man and a president. The years leading up to Roosevelt’s Presidency were filled with triumph, physical, and mental challenge. One thing that sticks out of his past is that both of the most important women in his life died within a few hours of each other. Roosevelt’s wife and mother both died on the same day in the year 1884. The one thing that came out of these tragedies was Theodore’s daughter Alice Lee, whom was left to be taken care of by his sister and husband. Shortly after losing his wife and mother Roosevelt fled for the Dakota’s, where he once again fell in love with the western frontier. Once living on the frontier Roosevelt bought a ranch and cattle and started to hunt. But not all good things can last forever. During one winter more than half of his cattle had been killed because of the bad weather and because of this and many other reasons Roosevelt left the Dakota’s and headed back east to live with his childhood sweetheart Edith Kermit Carow. Also while r aising Alice his first born daughter, Teddy and Edith had five of their own children. After returning to New York, Roosevelt continued his writing career, which began with the publication of his book, The Naval War of 1812, in 1882. Later on, Roosevelt also resumed his political career by running unsuccessfully for mayor of New York City in 1886. After this Roosevelt campaigned for