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Technical expertise as an ethical form: towards an ethics of distance.

The present article proceeds from the observation that the therapeutic relationship is basically unequal. This inequality essentially concerns the respective situation of the patient and his or her doctor vis-à-vis medical knowledge. A strict professionalism guarantees that this inequality remains factual and without essential value. Yet, if both partners unreflectively allow affectivity excessively to intrude into their relationship, their behaviour may then be inspired by subconscious, rather than rational, motives. In that case, the unverifiable allegations of philanthropy or paternalism may be used to rationalise a kind of 'medical sadism' which attempts to justify the will to humiliate the patient by means of the constraints inherent in medical care. The concept of ethical form is introduced as a non-verbal criterion of ethical reliability. It is mainly a way of training the will through the application of rationally justified rules of behaviour. In this context, it is suggested that an effort to remain constantly within the limits of professionalism represents a method of training for the achievement of some degree of ethical credibility in the therapeutic relationship. In the long term, such abstinence could constitute a sort of catharsis, and thereby help to reveal the non-rational motives in medical behaviour. Contrary to the belief prevailing in modern society, the established limits of medical knowledge are not so broad. The application of these limits would probably be the best method of preventing emotions from interfering undesirably in the therapeutic relationship.

Dehumanization↗

Autonomy, welfare and the treatment of AIDS.

Many AIDS-related issues are polarised. At the social level, civil rights or liberties are seen as being in conflict with general utility, and an analogous distinction is often assumed to exist at the one-to-one, individual level at which doctors work. In this paper the latter form of the distinction is argued to be false. By seeing autonomy as part of welfare, doctors can think more directly about such issues as paternalism, confidentiality, and consent. A number of these issues are discussed in the light of the revised conception of welfare, in the form of simplified case studies.

Acquired Immunodeficiency Syndrome↗

The student with a writing block--the ethics of psychotherapy.

The potential role of the psychotherapist as ethical interventionist is considered with reference to a patient who presented with a writing block. The case for the therapist to act paternalistically is followed by the counterargument which revolves around the respect for autonomy. A bridge between these two opposing positions is then offered which depends on viewing informed consent as a dynamic process. As part of this procedure it is made clear that while autonomy is the desired end-state of psychotherapy, it is not the be all and end all of treatment. Therapy is necessarily value-laden since it aims for the enhancement of the patient's state of autonomy; it is value-free inasmuch as the therapist desists from guiding the patient in how she should live her life.

Adult↗

Against the magnanimous in medical ethics.

Supererogatory acts are considered by some to be part of medicine, whereas others accept supererogation to be a gratuitous virtue, to be extolled when present, but not to be demanded. The present paper sides with those contending that medicine is duty-bound to benefit patients and that supererogation/altruism must per definition remain outside and beyond any role-description of the profession. Medical ethics should be bound by rational ethics and steer away from separatist views which grant exclusive privileges but also create excessive demands, way beyond what physicians perform or are willing and able to offer.

Altruism↗

Autonomy, religious values, and refusal of lifesaving medical treatment.

The principal question of this paper is: Why are religious values special in refusal of lifesaving medical treatment? This question is approached through a critical examination of a common kind of refusal of treatment case, one involving a rational adult. The central value cited in defence of honouring such a patient's refusal is autonomy. Once autonomy is isolated from other justificatory factors, however, possible cases can be imagined which cast doubt on the great valuational weight assigned it by strong anti-paternalists. This weight is sufficient, in their estimation, to justify honouring the patient's refusal. There is thus a tension between the strong anti-paternalist's commitment to the sufficiency of autonomy and our intuitions respecting such cases. Attempts can be made to relieve this tension, such as arguing that patients aren't really rational in the circumstances envisaged, or that other values, such as privacy or bodily integrity, if added to autonomy, are sufficient to justify an anti-paternalistic stance. All such attempts fail, however. But what does not fail is the addition of religious freedom, freedom respecting a patient's religious beliefs and values. Why religious freedom reduces the tension is then explained, and the specialness of religious beliefs and values examined.

Attitude to Health↗

Involving patients in do not resuscitate (DNR) decisions: an old issue raising its ugly head.

A recent paper in this journal (1) suggests that involving terminally ill patients in choices concerned with Cardio-Pulmonary Resuscitation (CPR) produces 'psychological pain' and therefore is ill-advised. Such a claim rests on anecdotal observations made by the authors. In this paper I suggest that drawing conclusions in ethics, no less than in science, requires a rigorous framework and cannot be relegated to personal observation of a few cases. The paper concludes by suggesting that patients, if we acknowledge their valid interest in making their own choices, must themselves be allowed to make a prior choice about choosing. Those who may not wish to choose may properly be relieved of this burden and may allow another to choose for them. Routinely allowing others to make choices for competent adults, however, is likely to decrease communication with the dying patient and to introduce an atmosphere of suspicion and fear and to exclude the competent patient from his/her rightful place in the community.

Attitude to Death↗

A defence of medical paternalism: maximising patients' autonomy.

All illness represents a state of diminished autonomy and therefore the doctor-patient relationship necessarily and justifiably involves a degree of medical paternalism argues the author, an American medical student. In a broad-ranging paper he discusses the concepts of autonomy and paternalism in the context of the doctor-patient relationship. Given the necessary diminution of autonomy which illness inflicts, a limited form of medical paternalism, aimed at restoring or maximising the patient's autonomy is entirely acceptable, and indeed fundamental to the relationship he argues. However, the exercise of this paternalism should be flexible and related to the current 'level of autonomy' of the patient himself. An editorial in this issue comments briefly on this paper.

Decision Making↗

Effects of domestication on animal behaviour.

Centuries of domestication of animals by civilised man have had many measurable effects on the various species involved, but only in relatively recent history has scientific curiosity been directed to assessing their extent. The process of domestication is analysed and its known effects on animals reviewed through observations of and experiments with various species of domesticated animals conducted by researchers into animal psychology and biology. The known facts on the effects of domestication in animals are extrapolated in an attempt to determine to what extent modern man himself has been domesticated in the urban environment.

Adaptation, Biological↗

Costs and potential benefits of parental care in the nocturnal fat-tailed dwarf lemur (Cheirogaleus medius).

Parental care should evolve only if fitness benefits exceed fitness costs. In Cheirogaleus medius, a small nocturnal lemur of western Madagascar, we found the peculiar situation of considerable parental care by both sexes, combined with an extremely high rate of extra-pair young (EPY). In this paper, we try to elucidate the costs and benefits of parental care in C. medius, and we discuss hypotheses as to why males might actively participate in raising young, especially with regard to the high rate of EPY. The study was carried out in the dry deciduous forest of western Madagascar between 1996 and 2001. The most important components of parental care in C. medius are babysitting and guarding of the young. Observational data suggest that thermoregulatory demands during the first days after birth and defence from predators may be the driving factors selecting for this infant care behaviour. The reproducing individuals of both sexes incur considerable energetic costs by this behaviour, resulting in reduced fat stores and body condition in comparison to non-reproducing individuals. The reason why males also care for EPY remains elusive. We propose that males might not be able to detect individual relatedness and that they would jeopardise the survival of their own young if they gave no parental care. Alternatively, they might gain advantages other than direct fitness from raising EPY, for example if caring behaviour increases their chances in further reproduction, or if EPY are fathered by close kin.

Animals↗

Parental behavior in Saguinus fuscicollis ssp. (Callithricidae).

Carrying and nursing of infants were recorded in 7 groups during the first 40 days postpartum. All members of all groups participated in carrying the infants. Dominant males tended to carry most frequently, followed by mothers and nonbreeding, mostly juvenile individuals. The role of early experience in caring for infants in the development of adequate parental behavior and rearing success is discussed.

Animals↗

Effects of age, sex, and reproductive status on scent marking frequencies in the golden lion tamarin, Leontopithecus rosalia.

This study reports on the longitudinal changes in scent marking frequencies of male and female lion tamarins in relation to age, reproductive status, and group composition. Juvenile males and females in family groups and subordinate males in trios (2 males, 1 female) scent marked infrequently. Juvenile females scent marked less than juvenile males and began scent marking later. Adult pair-bonded males and females scent marked with similar frequencies. Females showed scent marking increases during mid-pregnancy, but their scent marking decreased both before and again after parturition. Both males and females exhibited decreases in scent marking while transporting dependent infants.

Age Factors↗

The behavioral repertoire of the black-and-white ruffed lemur, Varecia variegata variegata (Primates: Lemuridae).

A stable social group of 7 semifree-ranging black-and-white ruffed lemurs (Varecia variegata variegata) was studied for 4 months to catalog the behavioral repertoire of this species. Observations focussed on particular aspects of behavior were conducted before and after this 4-month period to supplement information gathered. Behavior in 11 major categories is detailed: postures, terrestrial locomotion, arboreal locomotion, feeding behavior, vocalizations, scent-marking, affinitive social behavior, agonistic social behavior, play behavior, sexual behavior, and parental behavior. Ruffed lemurs frequently used body positions and locomotor patterns unusual among lemurids, including bipedal hanging and long-descent leaps. These behaviors reinforce dental evidence that Varecia are among the most frugivorous of the Malagasy lemurs. Low intragroup cohesion, infrequent social interaction, and antiphonal use of several long-distance vocalizations suggest that ruffed lemurs naturally exhibit fission-fusion sociality. Social structure based on interindividual familiarity probably extends across foraging parties for several of the diurnally active lemurs; however, thus far only Varecia seems likely to exhibit fission-fusion sociality analogous to that seen in spider monkeys and chimpanzees.

Animals↗

Maternal differences in infant carriage in golden-headed lion tamarins (Leontopithecus chrysomelas).

Infant-carrying behaviour was observed in two families of captive golden-headed lion tamarins. Although the young were raised in almost identical social situations, we found a reversed involvement of mother-father pairs in the amount of time they carried their offspring. In one case, the parental division of carrying behaviour was consistent with the standard description for callitrichids in that the adult male was the primary carrier. In the other family, the mother carried the infant considerably more than the male. Comparison of transfer initiations and transfer times showed that maternal choice operated. It is suggested that maternal behavior may depend primarily on the female's physical and hormonal condition.

Animals↗

The vocal repertoire of the ringtailed lemur (Lemur catta).

The vocal repertoire of the ringtailed lemur (Lemur catta) is described quantitatively and spectrographically. Structure, usage and inferred function of the vocalizations of adults and immatures are examined and discussed. The size, acoustic variability and development of the ringtailed lemur's vocal repertoire are compared to prior assessments for this species as well as for other primates. With up to 22 different adult call types, the ringtailed lemur has a moderately large vocal repertoire for a primate.

Aging↗