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PubMed2001

The ethics of aggregation and hormone replacement therapy.

The use of aggregated quality of life estimates in the formation of public policy and practice guidelines raises concerns about the moral relevance of variability in values in preferences for health care. This variability may reflect unique and deeply held beliefs that may be lost when averaged with the preferences of other individuals. Feminist moral theories which argue for attention to context and particularity underline the importance of ascertaining the extent to which differences in preferences for health states reveal information which is morally relevant to clinicians and policymakers. To facilitate these considerations, we present an empirical study of preferences for the timing and occurrence of health states associated with hormone replacement therapy (HRT). Sixteen women between the ages of 45 and 55 were enrolled in this pilot study. Their preferences regarding five health states associated with HRT (menopausal symptoms. side effects of HRT, breast cancer, myocardial infarction, and osteoporosis) were assessed in quantitative terms known as utilities. Two standard methods, the visual analog scale (VAS) and the standard gamble (SG), were used to assess utility and time preference (calculated as a discount rate). The wide variability of responses underlines the importance of tailoring health care to individual women's preferences. Policy guidelines which incorporate utility analysis must recognize the normative limitations of aggregated preferences, and the moral relevance of individual conceptions of health.

Cost-Benefit Analysis↗
PubMed2003

Why we need the independent sector: the behavior, law, and ethics of not-for-profit hospitals.

Among the major forms of corporate ownership, the not-for-profit ownership form is distinct in its behavior, legal constraints, and moral obligations. A new empirical analysis of the American Hospital industry, using eleven years of data for all urban general hospitals in the country, shows that corporate form accounts for large differences in the provision of specific medical services. Not-for-profit hospitals systematically provide both private and public goods that are in the public interest, and that other forms fail to provide. Two hypotheses are proposed to account for the findings, one legal and one moral. While no causal claims are made, not-for-profit hospital behavior is consistent with the behavior required by law and morality. The moral argument, developed as a preliminary theory of not-for-profit ethics, also provides a potential reason to prefer not-for-profit hospitals. The findings provide a new justification for the not-for-profit tax exemption for hospitals, and also suggest new uses for ownership categories as regulatory tools.

Ethics, Institutional↗
PubMed1994

Tube feeding. Internists' attitudes regarding ethical obligations.

BACKGROUND: Little is known about the attitudes of internists regarding their ethical obligation to provide or withhold tube feeding in three clinical contexts when patient preferences are not known: acute pneumonia, severe dementia, and persistent vegetative state. METHODS: A written questionnaire with patient scenarios was mailed to a randomized national sample of 1000 internist members of the American College of Physicians. RESULTS: Response was received from 58% of our sample (n = 581). Only physicians with personal experience with tube feeding decisions were included in the subsequent analysis (n = 326). Respondents were mostly male board-certified internists active in patient care in urban/suburban settings. Physicians demonstrated a predominant attitude for each scenario: 98% favored initiation of tube feeding for the patient with acute pneumonia; 84% opposed initiation of tube feeding for the patient with advanced dementia when depicted with a mixed happy/sad affect; and 80% favored withdrawal of tube feeding for the patient with established persistent vegetative state. Sixteen percent (n = 51) described tube feeding as basic humane care, whereas 84% (n = 265) believed tube feeding is medical therapy. Physicians were more opposed to tube feeding in certain patient scenarios than the literature suggests occurs in actual practice. CONCLUSIONS: Our data suggest that when patient wishes are not known, physician decisions regarding tube feeding are strongly influenced by prognosis. State legislation that categorizes tube feedings differently from other medical treatments conflicts with the judgment of the majority of internist respondents.

Adult↗
PubMed1990

The elderly and high technology medicine: a case for individualized, autonomous allocation.

The issues involved in decision making about the aggressiveness of future medical care for older persons are explored. They are related to population trends, the heterogeneity of older persons and a variety of factors involved in individual preferences. Case studies are presented to illustrate these points, as well as a review of pertinent literature. The argument is offered that, considering these many factors, a system of flexible, individualized care by informed patient preference, is more rational than the rationing of technological services by age.

Aged↗
PubMed1992

The negotiation of death: clinical decision making at the end of life.

The ability of medical science to prolong biological life through the use of technology raises the question of how far physicians should go in treating the terminally ill patient. In clinical decision making involving the dying patient, physicians, patients and families bring various perceptions and interpretations to the situation. These different realities must be negotiated in order to define the meaning of the situation and the meaning of various medical technologies. The patient's demise becomes a negotiated death, a bargaining over how far medical technology should go in prolonging life or in prolonging death. A case study of the process of ethical decision making in the foregoing of life-supporting therapy in an intensive care setting is presented and analyzed. The decision making process in this case follows a 'cascade' pattern rather than a controlled, reflective model. While ethicists view the withholding and withdrawing of life-supporting treatment as morally equivalent, physicians tend to make a distinction based on the perceived locus of moral responsibility for the patient's death. In the author's interpretation the moral responsibility for the patient's death by withdrawing treatment is shared with family members, while the moral responsibility for the patient's death by withholding treatment is displaced to the patient. The author suggests that an illusion of choice in medical decision making, as offered by the physician, begins a negotiation of meanings that allows a sharing of moral responsibility for medical failure and its eventual acceptance by patient, family and physician alike.

Aged↗
PubMed1987

Use of the alternating treatments design as a strategy for empirically determining language training approaches with mentally retarded children.

The present study was conducted as a practical demonstration of the potential utility of the alternating treatments design (ATD) in determining the most efficacious language training approach with mentally retarded children. Two subjects were chosen who used single words to communicate but who did not combine words to form sentences. Two sentence triads consisting of four words each and rated as equivalent in difficulty were trained. Each triad had one sentence trained using oral speech methods, a second trained using total communication methods, and a third sentence trained using a "modified" total communication approach. Each training procedure involved chaining sentence parts, reinforcement, and prompting. Oral methods involved presenting vocal stimuli and requiring vocal responses. Total communication methods involved presenting vocal and signed stimuli and requiring vocal and signed responses. The "modified" total communication approach also involved presenting vocal and signed stimuli, but required only vocal responses. For the initial sentence triad with each child, an alternating treatments design was used to determine the relative efficacy of the three language training methods. This approach was repeated with a second sentence triad for each child using a multiprobe technique within a multiple baseline design. Results were consistent within each subject but differed across subjects, with one child benefitting most from total communication methods and the other benefitting most from oral speech methods. Results were discussed in terms of the utility of the alternating treatments design as a potentially useful aid to traditional decision-making in the selection of language training strategies commonly employed with mentally retarded children.

Adolescent↗
PubMedDate not supplied

Predicting survival in malignant skin melanoma using Bayesian networks automatically induced by genetic algorithms. An empirical comparison between different approaches.

In this work we introduce a methodology based on genetic algorithms for the automatic induction of Bayesian networks from a file containing cases and variables related to the problem. The structure is learned by applying three different methods: The Cooper and Herskovits metric for a general Bayesian network, the Markov blanket approach and the relaxed Markov blanket method. The methodologies are applied to the problem of predicting survival of people after 1, 3 and 5 years of being diagnosed as having malignant skin melanoma. The accuracy of the obtained models, measured in terms of the percentage of well-classified subjects, is compared to that obtained by the so-called Naive-Bayes. In the four approaches, the estimation of the model accuracy is obtained from the 10-fold cross-validation method.

Algorithms↗
PubMed2001

Ethical decision making in neonatal units--the normative significance of vitality.

This article will be concerned with the phenomenon of vitality, which emerged as one of the main findings in a larger grounded theory study about life and death decisions in hospitals' neonatal units. Definite signs showing the new-born infant's energy and vigour contributed to the clinician's judgements about life expectancy and the continuation or termination of medical treatment. In this paper we will discuss the normative importance of vitality as a diagnostic cue and will argue that vitality, as a sign perceived by doctors and nurses, has moral significance and represents a legitimate contribution to clinical decision-making in difficult cases where the child's life is at stake. We will argue that these clinical intuitions can be justified on a moral basis but only with certain qualifications that accounts for a certain objectivity and intersubjective reliability in the therapeutic judgements.

Decision Making↗
PubMed1987

Changes in doctor/patient communication of a terminal prognosis: a selective review and critique.

Numerous studies have examined the willingness of physicians to communicate a terminal prognosis to a patient. The pattern of results suggests that there has been a shift from a widespread tendency not to tell patients of such a prognosis in the 1950s to a widespread tendency to tell in the 1980s. This paper reviews ten articles which document this apparent shift. In addition, this review reveals methodological, statistical, and theoretical shortcomings of the literature. These shortcomings seriously undermine the ability to use this literature as a basis for supporting what might otherwise be a reasonable claim concerning the shift in physicians' behavior. Hence, the present paper examines the nature of these shortcomings and makes suggestions for rectifying such problems in future research.

Attitude to Death↗
PubMed2002

Abortion and neonaticide: ethics, practice, and policy in four nations.

Abortion, particularly later-term abortion, and neonaticide, selective non-treatment of newborns, are feasible management strategies for fetuses or newborns diagnosed with severe abnormalities. However, policy varies considerably among developed nations. This article examines abortion and neonatal policy in four nations: Israel, the US, the UK and Denmark. In Israel, late-term abortion is permitted while non-treatment of newborns is prohibited. In the US, on the other hand, later-term abortion is severely restricted, while treatment to newborns may be withdrawn. Policy in the UK and Denmark bridges some of these gaps with liberal abortion and neonatal policy. Disparate policy within and between nations creates practical and ethical difficulties. Practice diverges from policy as many practitioners find it difficult to adhere to official policy. Ethically, it is difficult to entirely justify perinatal policy in these nations. In each nation, there are elements of ethically sound policy, while other aspects cannot be defended. Ethical policy hinges on two underlying normative issues: the question of fetal/newborn status and the morality of killing and letting die. While each issue has been the subject of extensive debate, there are firm ethical norms that should serve as the basis for coherent and consistent perinatal policy. These include 1) a grant of full moral and legal status to the newborn but only partial moral and legal status to the late-term fetus 2) a general prohibition against feticide unless to save the life of the mother or prevent the birth of a fetus facing certain death or severe pain or suffering and 3) a general endorsement of neonaticide subject to a parent's assessment of the newborn's interest broadly defined to consider physical harm as well as social, psychological and or financial harm to related third parties. Policies in each of the nations surveyed diverging from these norms should be the subject of public discourse and, where possible, legislative reform.

Abortion, Eugenic↗
PubMed1987

Feeding of severely demented patients in institutions: interviews with caregivers in Israel.

In an exploratory, open-ended, and non-random study, 60 health care workers in nine long-term care institutions in Israel were questioned regarding their experiences, thoughts and feelings related to force feeding senile demented patients. The main findings were analysed according to an ethical decision-making model. Israeli care workers tended to ground their explanations in traditional Jewish sanctity of life ethics. Their actions as well as their emotional reactions seemed the logical outcome of this world view: patients were force fed and caregivers did not feel guilt for using force or accepting suffering, since they felt obliged to preserve life and thus their actions were right. They did feel ugly and upset about the situation. While most caregivers felt that force feeding was the only acceptable route in an institution, some suggested family home care where discretionary case by case ethics was seen as a viable alternative. This paper compares the Israeli interview results with those of the Swedish studies.

Attitude of Health Personnel↗
PubMed1990

Misunderstanding death on a respirator.

As Tom Tomlinson's study indicates, there is considerable misunderstanding and confusion among physicians and nurses working in the area. Brain death is often not well-understood by healthcare professionals and hence inadequately explained to relatives, leaving them confused as to whether their loved-one is alive or dead. Whilst these healthcare professionals are using whole-brain death as the criterion of death, they have no clear understanding of the definition of death which underpins the brain-death criterion. Lack of this philosophical rationale makes the use of the brain-death criterion a mere technicality, rather than the expression of a well-grounded conceptual and ethical understanding. The other difficulty is that a brain-dead respirator patient just does not look dead. This appearance of life, Tomlinson suggests, can trigger deep emotions in caregivers and family members which will compound the intellectual perplexity already felt by them.

Attitude↗
PubMed1991

Anencephalic infants as organ sources.

Liveborn anencephalic infants cannot be used legally as sources for vital organs in the United States and Canada. Understandably, knowledgeable physicians and bioethicists are divided over the ethics of such use and hold various views on whether the legal status of anencephalic newborns should ever be changed. Even if anencephalic newborns could be utilized as organ sources, at best a few hundred infants needing transplant organs would be saved each year. Primarily, this is because the number of anencephalic newborns is likely to diminish due to prenatal diagnosis resulting in abortions. However, the case of anencephalic infants and their treatment is paradigmatic in raising questions far beyond mere organ transplantation.... This analytical report is given against the backdrop of a burgeoning medical technology which can sustain human life far beyond that generally regarded as a meaningful, functional life. The report has three sections: first, a description of the approaches to the use of anencephalic infants in North America over the last five years; second, a summary of the results of a survey of informed clinicians and ethicists; and third, an indication of the leading ethical issues raised by human individuals at the border of life.

Anencephaly↗
PubMed1993

Unrequested termination of life: is it permissible?

CONCLUSION: One can appreciate and understand why doctors take action to terminate life without being requested by the patient who is suffering unbearably and pointlessly. But in my opinion such action is not permissible from a moral point of view. In the first place there is a danger that interests other than those of the patient will play a decisive role. Furthermore, it is not permissible because the interest of society as a whole is at stake. The safety of all future patients would no longer be guaranteed. It is also not allowed because the medical profession must constantly be on its guard so that it does not become caught up in the situations described above. In nearly every case it should be possible for doctor and patient to discuss the termination of life explicitly and at an early stage. The ultimate reason why termination of life without request of the patient is not permissible is that in principle it will never be possible to draw a clear dividing line between unrequested and unwanted termination of life. However, it is conceivable that in certain cases the conflict of loyalties will be such that unrequested termination of life is justified. In the rare extreme case of an inescapable conflict of equally stringent duties, it may just be necessary to do something which in essence is impermissible.

Altruism↗