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In an earlier article in this journal, I advanced five ethical arguments in favour of a voluntary, unpaid system of blood donation. In his reply to my article, Hugh McLachlan criticised one of those arguments, namely, the argument that an unpaid system promotes altruism and social solidarity. In this reply to Dr. McLachlan, I maintain that his criticism is misguided, and that he appears unclear not only about my own argument, but also about his own.
This is a continuation of and a development of a debate between John Keown and me. The issue discussed is whether, in Britain, an unpaid system of blood donation promotes and is justified by its promotion of altruism. Doubt is cast on the notions that public policies can, and, if they can, that they should, be aimed at the promotion and expression of altruism rather than of self-interest, especially that of a mercenary sort. Reflections upon President Kennedy's proposition, introduced into the debate by Keown, that we should ask not what our country can do for us but what we can do for our country is pivotal to this casting of doubt. A case is made for suggesting that advocacy along the lines which Keown presents of an exclusive reliance on a voluntary, unpaid system of blood donation encourages inappropriate attitudes towards the provision of health care. Perhaps, it is suggested, and the suggestion represents, on my part, a change of mind as a consequence of the debate, a dual system of blood provision might be preferable.
Seroprevalence monitoring of HIV in pregnant women by anonymized unlinked testing has been widely adopted in the UK and other countries. The scientific rationale is to eliminate participation and selection bias. The ethical justification is that the public good outweighs any harm to individuals. The assumption has been that individuals have had their autonomy respected by the offer of informed consent. In the light of new scientific evidence, it is doubtful that the public good is best served by the continuation of anonymously testing women receiving antenatal care. It is submitted that it is no longer ethical for health professionals to refrain from informing pregnant women of the benefits of voluntary named testing, or to request their consent to anonymized testing. The legal and moral concept of duty of care is examined, and the abrogation of this duty through anonymization is explained.
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Should blood be bought and sold is in crude terms the question asked and answered by Richard Titmuss in his recent book The Gift Relationship. Dr Raymond Plant, a lecturer in philosophy at Manchester University, analyses Titmuss' arguments in a paper which we are printing in two parts. Titmuss has taken the provision of blood as his example of the gift relationship--and by extension that of health care generally. Dr Plant considers in turn each of Titmuss' arguments that blood should not be a marketable commodity, the moral objections to which seem to be the erosion of freedom and of truth telling, the separation of society through the cash nexus, and its converse that the provision of health care is a means for the integration of society. Dr Plant also examines the views of other commentators on the Titmuss' theory of the value of a 'free' blood transfusion service and other medical care as a means of integration in society, and ends with his promise that in the second part of his paper he will examine Titmuss' principles not in terms of the market but rather as related to the principle of social justice.
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Not all sites performing mammography produce optimal images at acceptably low doses. To address this situation, a voluntary accreditation program was instituted through the American College of Radiology. Each site applying for accreditation completes a detailed questionnaire about facilities and equipment, personnel, and quality control. Each unit at each site is evaluated by a medical physicist for clinical and phantom image quality and for average glandular dose. Although a site is accredited for 3 years, the performance of each unit is audited annually. Of 11,162 units for which accreditation was sought, only 5,856 (68%) passed at the first attempt, with another 18% passing after reapplication. The major reason for failure was inadequate clinical images, followed by inadequate phantom images, both inadequate clinical and phantom images, and inadequate quality control records. In a performance audit of 20 new units, an average of 5.8 problems were encountered per unit, the majority of which adversely affected image quality. These results support the requirement of equipment performance audits and raise the question of whether similar problems exist in other areas of medical imaging.
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The Human Genome Project is likely to exacerbate historic tendencies to balance demographic concerns on the backs of women. This kind of policy is unjustified in law and violates classic theories of justice. Reproductive decision making, which affects women personally, is not the legitimate domain of community concern or manipulation.
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In 1976 the Connecticut Valley Hospital, the Yale University School of Law, and the department of psychiatry of the Yale School of Medicine, undertook a project in which all involuntary patients at the hospital, a total of 107, were reviewed by three interdisciplinary panels, each composed of a law student, a psychiatric resident, and a hospital social worker. The major purposes of the project were to identify those patients entitled to release under the Donaldson criteria, to develop a model review procedure, and to assess the need for alternative placements. The panels found no patients resembling Kenneth Donaldson, but they did find 53 per cent of the patients inappropriately detained on involuntary status. However, in most cases the recommendation was transfer to a nursing home because of the patient's high degree of disability. The authors emphaxize the importance of periodic external reviews of commitment status.