Biomedical subjects
Publications and source records attributed to L R Churchill.
Age-rationing of health care is beginning to be widely debated. Two recent proposals are examined. It is argued that age-rationing proposals must be viewed in the light of current rationing practices, and that all such proposals must be placed in the context of a more just overall health care system.
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In medical ethics, principles have an important but frequently overextended role. The need for exact answers and moral formulae sometimes leads to the misuse of principles, such that they usurp the central place of persons and become ends in themselves. The Baby Jane Doe case is discussed as a prominent instance of both the proper uses and abuses of principles. A more fitting role for principles is described and illustrated, stressing the use of principles as tools of moral discernment and the time-laden character of moral judgments.
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The moral dilemmas of selective nontreatment of handicapped newborns have been widely discussed in the United States since the early 1970s. Weir's book is the first systematic ethical analysis of the pertinent legal and medical factors. His book is reviewed in light of the current government regulations and the formation of Infant Care Review Committees in U.S. hospitals. Weir develops ethical criteria for decision-making about malformed infants and suggests decisions about treatment be made on the basis of disease categories. The implications of Weir's recommendations for a number of critical cases are discussed.
The idea of an ideal observer is frequently employed in ethical reasoning and has recently been introduced into medical ethics. The contemporary use of this idea, however, is deeply flawed. It ignores important social and personal dimensions of ethics. By espousing a perspective of observation removed from history and community, the ideal observer notion encourages a pretense of objectivity and overlooks the distortions of distance. If taken seriously as a model for choice, the ideal observer is incoherent, as it dispenses with the concrete moral agent and the locus of choice. Adam Smith's 'impartial spectator' is examined as a more adequate statement of the need for appreciating diverse perspectives in ethical choices.
A case of a patient with angina who was considered for coronary bypass surgery illustrates the issue of informed consent. Ethical and legal aspects and the inherent limitations of achieving consent must be considered. Physicians may have personal biases, which may lead to coerced consent, or may overwhelm the patient with information on potential complications of a proposed procedure, which may lead to consent without hope. Patient bias or misinformation may lead to misunderstood consent or, if the patient's judgment is distorted, to crisis consent. The patient's desire to defer the decision to the physician raises the question of whether such requested paternalism violates patient self-determination and invalidates consent or is an exercise of the patient's right to have his physician decide. The case presented exemplifies the patient-physician interaction needed for responsible paternalism.
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When a patient visits his doctor there is, as well as a spoken dialogue, also an unspoken, or tacit, dialogue between them. This may not be evident unless that dialogue breaks down when the psychological or moral terms of reference of each are seen to be different. The author of this paper tries to elucidate the framework in which physician and patient think, and in so doing allow an understanding of why the physician may appear to be rigid and authoritarian in his dealing with his patients and the patient uncooperative.
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