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PubMed1994

Moral and religious objections by hospitals to withholding and withdrawing life-sustaining treatment.

A patient's right to decide about life-sustaining treatment may conflict with the policies of health care facilities that refuse on the basis or religious or moral convictions to honor certain decisions to forgo treatment. The New York State Task Force on Life and the Law examined the prevalence and nature of facility conscience objections to the refusal of life-sustaining treatment by conducting a survey of New York hospitals. Written questionnaires were distributed to hospitals in New York State. Fifty-eight percent of the New York State hospitals responded. Twenty-nine percent of the respondents indicated that their hospital would object on grounds of conscience either to withholding or to withdrawing life-sustaining treatment in at least one of the twelve hypothetical cases presented. Hospitals were more likely to have "no policy" for withdrawing than for withholding treatment. Only 10% of the hospitals that would object to decisions to forgo treatment on religious or moral grounds had stated the objections in writing. The patient's medical condition and the type of life-sustaining treatment to be withdrawn or withheld are important factors in determining whether a hospital will object on grounds of conscience. The imminence of death appeared more decisive than the degree of debilitation or disability as a factor in the willingness to accept decisions to forgo life-sustaining treatment. Hospitals should establish clear, written policies about their objections to forgoing treatment so that patients and their families can evaluate whether the facility meets their needs.

Advisory Committees↗
PubMed2005

Influenza vaccination in Dutch nursing homes: is tacit consent morally justified?

OBJECTIVES: Efficient procedures for obtaining informed (proxy) consent may contribute to high influenza vaccination rates in nursing homes. Yet are such procedures justified? This study's objective was to gain insight in informed consent policies in Dutch nursing homes; to assess how these may affect influenza vaccination rates and to answer the question whether deviating from standard informed consent procedures could be morally justified. DESIGN: A survey among nursing home physicians. SETTING & PARTICIPANTS: We sent a questionnaire to all (356) nursing homes in the Netherlands, to be completed by one of the physicians. RESULTS: We received 245 completed questionnaires. As 21 institutions appeared to be closed or merged into other institutions, the response was 73.1% (245/335). Of all respondents 81.9% reported a vaccination rate above 80%. Almost 50% reported a vaccination rate above 90%. Most respondents considered herd immunity to be an important consideration for institutional policy. Freedom of choice for residents was considered important by almost all. Nevertheless, 106 out of 245 respondents follow a tacit consent procedure, according to which vaccination will be administered unless the resident or her proxy refuses. These institutions show significantly higher vaccination rates (p < 0.03). CONCLUSIONS: In our discussion we focus on the question whether tacit consent procedures can be morally justifiable. Such procedures assume that vaccination is good for residents either as individuals or as a group. Even though this assumption may be true for most residents, there are good reasons for preferring express consent procedures.

Aged↗
PubMed2006

Moral dilemmas in neonatology as experienced by health care practitioners: a qualitative approach.

During the last two decades there has been an enormous development in treatment possibilities in the field of neonatology, particularly for (extremely) premature infants. Although there are cross-cultural differences in treatment strategy, an overview of the literature suggests that every country is confronted with moral dilemmas in this area. These concern decisions to initiate or withhold treatment directly at birth and, later on, decisions to withdraw treatment with the possible consequence that the child will die. Given that the neonate cannot express his or her own will, who will decide? And on the basis of what information, values and norms? We explored some of these issues in daily practice by interviewing a small sample of health care practitioners in a Dutch university Neonatal Intensive Care Unit (NICU). It turned out that experiencing moral dilemmas is part of their daily functioning. Nurses underline the suffering of the newborn, whereas physicians stress uncertainty in treatment outcome. To make the best of it, nurses focus on their caring task, whereas physicians hope that future follow-up research will lead to more predictable outcomes. As for their own offspring, part of these professionals would hesitate to bring their own extremely premature newborn to a NICU. For the most oppressing dilemma reported - terminating an already initiated treatment - we propose the concept of 'evidence shift' to clarify the ambiguous position of uncertainty in decision making.

Attitude of Health Personnel↗
PubMed2005

Moral pedagogy and practical ethics.

Online science and engineering ethics (SEE) education can support appropriate goals for SEE and the highly interactive pedagogy that attains those goals. Recent work in moral psychology suggests pedagogical goals for SEE education that are surprisingly similar to goals enunciated by several panels in SEE. Classroom-based interactive study of SEE cases is a suitable method to achieve these goals. Well-designed cases, with appropriate goals and structure can be easily adapted to courses that have online components. It is less clear that exclusively online methods can support the wide range of goals necessary to good moral pedagogy in SEE, though there seems no a priori reason to rule this out. Only careful, goal-based assessment of online case study SEE teaching can resolve this question.

Computer-Assisted Instruction↗
PubMed1986

Stroke: morale, family functioning, health status, and functional capacity.

Twenty-two stroke patients and their spouses were studied. All patients were living at home and had had a stroke at least one year previously. Of the 22 patients 14 were men and eight were women. Couples were assessed on the variables of morale, family functioning, health status, and patient functional capacity. For all variables, patient-spouse and husband-wife differences were tested. Couples from a previously studied random community sample were matched to the stroke couples on age and socioeconomic status (SES). Identical morale, family functioning, and health status data collected on these couples were compared to the stroke data. The results included the following: Stroke patients and their spouses were healthy on all variables. Members of the couple did not differ on most variables whether compared as husband-wife or patient-spouse. Wives from the two samples did not differ on any variable. Husbands from the stroke sample differed from the matched husbands on only one health variable--the number of doctor visits made in the past six months.

Activities of Daily Living↗
PubMed1987

Developmental origins of moral masochism: a failure-to-thrive toddler's interactions with mother.

The case of a toddler diagnosed as failure to thrive with an unusual history of "accidents" illustrates the circumstances which may account for the infant's intense attachment to a sadistic love object and lead to moral masochism in adulthood. The observed behaviors of the toddler in interaction with mother show the pathological consequences of the infant's openness to influences of the social environment. He becomes attuned to his mother's wishes and performs behaviors which successfully evoke her attention and reciprocity even if these behaviors are contradictory to his survival. The mother's own experiences with unempathic and hostile parents are reflected in her attitudes and behaviors to the child. Suffering and victimization evoke her interest although she lacks the capacity for an empathic response to pain. Berliner's work on the origin of moral masochism, as well as the work of Steele on generational repetition, suggest the processes through which the infant's attachment to a sadistic mother gives rise to masochistic tendencies which may be reenacted throughout life in an effort to reproduce the affective feelings associated with mother's love and affection.

Attention↗
PubMed1991

Adverse selection, moral hazard, and wealth effects in the Medigap insurance market.

Using data from a longitudinal study of the recently retired we attempt to separate the moral hazard effect of Medicare supplementary (Medigap) insurance on health care expenditures from the adverse selection effect of poor health on Medigap coverage. We find evidence of adverse selection, but its magnitude is unlikely to create serious efficiency problems. Taking adverse selection into account reduces the estimate of the moral hazard effect. In addition, we find a strong positive wealth effect on the demand for supplementary insurance.

Aged↗
PubMed1987

Reproduction trends and the emergence of moral panic.

Are we witnessing a moral panic or a moral evaluation in the responses to the new reproductive technologies? Locating women in reproductive technology is a particularly powerful way into a discussion of values and consequences, intended or unintended. Twelve areas are isolated for discussion beginning with issues of definition and location: What is reproductive and genetic engineering? and How does human reproduction fit into bio-technological developments generally? Next issues are raised about how the new developments are being shaped ideologically and how they are being promoted by the state. A series of legal issues affecting women, men, children, embryos and fetuses follow. The focus then shifts to the way women are ideologically constructed: Why is there an assumption that woman = mother, and mother = heterosexual married or stable cohabiting woman?--and socially controlled: Why assume technological change in human reproductive processes means the basic subordination of women to men will not alter? The usefulness of the new technologies in relieving involuntary childlessness is then queried which leads on to a questioning of whether these developments are qualitatively different from other technologies used in human reproduction. Futuristic concerns such as the importance of the male pregnancy and the social consequences of fully medicalising human reproduction are raised. The last area to be considered is protest by women and suggested alternative approaches to increase the social visibility and recognition of the needs and interest of women in the current and potential use of the new medical and scientific developments.

Female↗
PubMed2005

Empirical uncertainty and moral contest: a qualitative analysis of the relationship between medical specialists and the pharmaceutical industry in Australia.

Alliances between the medical profession and the pharmaceutical industry have become increasingly widespread in recent years. While there are clearly benefits for doctors and their patients derived from the medical profession working with industry, concern has arisen that the commercial imperative of industry may conflict with physicians' independence and professional integrity. This paper reports the findings of an in-depth interview study with 50 Australian medical specialists undertaken to explore how and why they interact with the pharmaceutical industry and to gain insight into specialists' moral evaluation of the relationship and its consequences. Analysis of the qualitative data led to the categorizing medical specialists into three types--Confident Engagers, Ambivalent Engagers and Avoiders--based on their descriptions and evaluations of their relationship. The majority of interviewees believed that some relationship with the pharmaceutical industry was inevitable, that there were both risks and benefits associated with the relationship and that as individuals they were competent in minimizing the risks and maximizing the benefits. However, their views diverged on the extent and magnitude of the risks and benefits. The data suggested that there is considerable variance in specialists' judgments of what constituted appropriate industry largesse. Specialists' relationship with the pharmaceutical industry has inherent tensions that are managed by different doctors in different ways. Moral evaluation of the relationship and its consequences varies and the ethical concerns surrounding the relationship appeared as an area of contest. The findings suggest that in developing normative guidelines for academic and professional practice, policy makers should recognise and account for the complexity of the relationship and for the variation in medical specialists' views and feelings.

Australia↗
PubMed2000

Moral hazard in physician prescription behavior.

I examine whether the choice made by physicians concerning what drug version--trade-name or generic--to prescribe is subject to moral hazard. I use a data set containing information on exactly what drug and what version was prescribed at a particular patient visit to the physician. The results indicate that physicians' habits and the tastes acquired by patients are important. However, costs also matter. Patients having to pay large sums out-of-pocket are less likely to have trade-name versions prescribed than patients getting most of their costs reimbursed. This indicates moral hazard.

Decision Making↗
PubMed1997

Politicizing abortion: personal morality and professional responsibility of residents training in the United States.

Ever-increasing technological innovations surrounding birth are creating new challenges in biomedical ethics in U.S. obstetrics. The politicization of abortion has augmented these challenges and led to increased conflict between physicians' personal morality and professional responsibility. This paper focuses on some of the problems generated by abortion policies and procedures in an obstetric/ gynecology residency program. Examples of conflicts among residents are presented to demonstrate the effect of pluralistic moral perspectives. A system is described where some residents will do abortions and some will not. Patients seeking abortion are often treated in an unprofessional manner when it appears that a conflict exists between the values of patients and those of residents. Unless the socialization of residents includes ethical training, defined educational policy and institutional direction, ethical dilemmas will lead to increased resident stress, an inadequate doctor-patient relationship and a continued shortage of physicians willing to perform abortions despite new policies called for in graduate medical education.

Abortion, Legal↗
PubMed2004

Brain responses to the acquired moral status of faces.

We examined whether neural responses associated with judgments of socially relevant aspects of the human face extend to stimuli that acquire their significance through learning in a meaningful interactive context, specifically reciprocal cooperation. During fMRI, subjects made gender judgments on faces of people who had been introduced as fair (cooperators) or unfair (defector) players through repeated play of a sequential Prisoner's Dilemma game. To manipulate moral responsibility, players were introduced as either intentional or nonintentional agents. Our behavioral (likebility ratings and memory performance) as well as our imaging data confirm the saliency of social fairness for human interactions. Relative to neutral faces, faces of intentional cooperators engendered increased activity in left amygdala, bilateral insula, fusiform gyrus, STS, and reward-related areas. Our data indicate that rapid learning regarding the moral status of others is expressed in altered neural activity within a system associated with social cognition.

Adult↗
PubMed2005

New breeds of humans: the moral obligation to enhance.

This paper argues that we have a moral obligation to enhance human beings. It is argued that if one is committed to the moral obligation to treat and prevent disease, one is also committed to genetic and other enhancement in so far as this promotes human well-being. It is argued that this is not eugenic but expresses our fundamental human nature: to make rational decisions and to try to improve ourselves. To be human is to strive to be better.

Ethics, Clinical↗
PubMedDate not supplied

Negative and positive genetic interventions: is there a moral boundary?

Some have claimed that negative genetic interventions are morally permissible while positive ones are not, but the distinction cannot be used to draw this moral boundary. Underlying the negative/positive distinction is a distinction between treatment and enhancement. The treatment/enhancement distinction at best provides an imperfect guide to which health care services we are obliged to provide and which we are not. It offers only some "warning flags" to help us think about what is permissible or not.

Genetic Engineering↗
PubMed2005

The relationship between sleep disturbance and morale in Japanese elderly people.

BACKGROUND: Complaints of sleep disturbance are common in elderly individuals. The quality of life (QOL) for people who have insomnia is thought to be worse than for those who do not have insomnia. In this study we investigated the influence of disturbed sleep on morale in elderly people who live independently. METHODS: A survey of the necessity of public nursing care for all those aged over 65 years was performed in Kumamoto city, Japan. Three hundred subjects from the elderly population living at home without special care were sampled at random and they filled out a questionnaire regarding sleep, psychiatric symptoms and attitudes towards their own aging. RESULTS: A logistic regression analysis found psychiatric symptoms and problems keeping awake to be independently related to a negative attitude towards one's own aging. Neither sleep, sex nor age demonstrated any relationship with the negative attitudes of elderly individuals. CONCLUSION: Excessive daytime sleepiness is related to poor morale regardless of both the quality and quantity of sleep and psychiatric symptoms.

Aged↗
PubMed2001

A moral economy of American medicine in the managed-care era.

The moral economy of American medicine has been transformed by contentious innovations in organization, administration, regulation, and finance. In many settings old fee-for-service incentives and disincentives have been replaced by those of "managed care", while in other settings they have been diluted or distorted. In the everyday care of patients, old and new may alternate or interact. These innovations may also be having secondary effects on participation in life-sciences research and the development and employment of new technologies, discouraging collective support for preliminary investigation and delaying adoption of improved goods and services until cost-reducing potential has already been realized. This motivational complexity, particularly in its moral dimensions, is hard to address using standard assumptions and methods. I argue for different assumptions, based on the clinical behavior of individual patients rather than the market behavior of aggregated consumers, and I describe a different method, based on an old idea in political economy. I then present a new way to explain the core obligations of clinicians, researchers, and planners and to interpret the policy problems they must now share.

Fee-for-Service Plans↗
PubMed2002

AIDS and sex: is warning a moral obligation?

Common-sense holds that morality requires people who know that they are infected with the Human Immunodeficiency Virus (HIV) to disclose this fact to their sexual partners. But many gay men who are HIV-positive do not disclose, and AIDS Service Organizations (ASOs) promote public-health policies based on safer sex by all, rather than disclosure by those who know that they are infected. The paper shows that the common-sense view follows from a minimal sexual morality based on consent. ASOs' seeming rejection of the view follows from their need to take seriously widespread weakness of will in the realm of sexuality. The author argues that gay men take themselves to follow the common sense view, but hold that the possibility of a partner's HIV infection is background information that need not be disclosed for sexual consent. This suggestion is criticized. The paper concludes with a consideration of HIV disclosure and sexual ethics outside of the gay community and of legal restrictions on the sexuality of the HIV-positive.

Acquired Immunodeficiency Syndrome↗
PubMed2002

The West's moral obligation to assist developing nations in the fight against HIV/AIDS.

The HIV/AIDS epidemic is increasingly a disease of the disadvantaged, a destroyer of nations, and a threat to global security and well-being. But this need not be so: the world has the scientific knowledge, technological innovations, and financial resources to significantly reduce the spread and suffering caused by the disease. This paper argues that the wealthy nations of the world, led by the United States, have a moral obligation to offer much greater assistance to developing countries where the epidemic is most severe. Using Zimbabwe as a case study, this essay examines the immediate and underlying factors behind the epidemic in order to make realistic and affordable policy recommendations that include new investments in global health care, debt relief, and long-term economic development. By demonstrating our ability to dramatically affect the future course and consequences of this unprecedented epidemic, the paper concludes that greater action is not only in the interest of public health, but is also a moral imperative. By investing the necessary resources to improve public health and to reduce global poverty, we promote and extend the fundamental rights and values that we profess to hold dear.

Communicable Disease Control↗