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Further thoughts on double effect: some preliminary responses.

Since the papers in this issue by Alan Donagan, Don Marquis, William Nelson and Warren Quinn raise complex and challenging questions about almost every aspect of my "Who is Entitled to Double Effect", I cannot, in the present context, provide more than preliminary responses to some of the more important issues they raise in the hope that this might contribute to further clarification of the doctrine of double effect (DDE).

Bioethical Issues↗

Transcendental health care ethics: beyond the medical model.

Recent health care ethics literature is heavily weighted in favor [of] examining problems associated with technological and other advances. This article challenges such a narrow focus of inquiry, maintaining that a broader conceptualization of the problems in health care is warranted. In part, this problem of focus can be attributed to the labeling of the field of study as "medical ethics" which reinforces a medical model approach to the exploration of problems. This particular perspective has proven inadequate for the purpose of describing the moral problems associated with health care. The health care professions, including medicine, have responsibilities toward individuals but also have wider responsibilities to society in general. These responsibilities are reflected in their codes of ethics. Thus, the purpose of moral philosophy with regard to health care ethics issues should not be constrained to "medical ethics" but should include broader appraisals of health care and the health care context.

Bioethical Issues↗

Avoiding "Cloudcuckooland" in ethics committee case review: matching models to issues and concerns.

... The special concerns of families, patients, and caregivers are inevitably interwoven among the difficult ethical issues that ethics committees confront when they review individual cases. Certain of these ethical issues and special concerns can be addressed more effectively by the use of one particular case review model. This means that no one model for case review is suited to address every ethically difficult patient care situation. When one case review model is used exclusively by an ethics committee, some issues and concerns will not be resolved effectively. This difficulty cannot be ameliorated by switching to another exclusive model. To do so would be to trade an Athens for a "Cloudcuckooland." The case review model selected by ethics committees must vary from case to case. The model that is chosen should be geared to resolve the ethical issues central to that situation and the special concerns of patient, family, and caregivers. An examination of the three received models [the committee as a whole, teams, and individual members or consultants] will show that each is particularly suited to resolve certain kinds of ethical issues and special concerns. Because of this, ethics committees should develop a method for choosing the most appropriate model for reviewing specific cases.

Bioethical Issues↗

Trends in the development of medical ethics in the USSR.

The study of professional ethics has a long tradition in the Soviet Union; medical ethics is a code of conduct as well as an academic discipline. The paper discusses the ethical issues in intensive care, the definition of death, abortion, euthanasia, and the moral aspects of medical mistakes.

Abortion, Induced↗

Ethical issues in transgenics.

The arguments of critics and concerns of the public on generating transgenic cloned animals are analyzed for the absence or presence of logical structure. Critics' arguments are symbolically compared with "genetic trespassing," "genetic speeding," or "going the wrong way," and responses are provided to these arguments. Scientists will be empowered to participate in the public discussion and to engage the critics on these issues as they consider thoughtful, plausible responses to their concerns. Temporary moratoriums are recognized as a plausible approach to dealing with possible concerns of new scientific advancements.

Animal Welfare↗

An ethics consultation service in a teaching hospital. Utilization and evaluation.

A newly established formal ethics consultation service in a university teaching hospital was prospectively evaluated. A physician-ethicist interviewed and examined patients, interviewed family and others as needed, and entered a formal consultation note in the medical record. The requesting physician and the consultant independently completed structured questionnaires. Fifty-one consultation requests were received from 45 physicians from seven departments between July 1, 1986, and June 30, 1987. Seventeen (33%) of 51 patients were in the intensive care unit, and 19 patients (37%) were fully oriented at the time of consultation. Overall, 61% of the patients survived to leave the hospital. The requesting physician sought assistance with withholding or withdrawing life-sustaining treatment in 49% of cases, with resuscitation issues in 37%, and with legal issues in 31%. Assistance with more than one issue was sought in 39 cases (76%). In 36 cases (71%), the requesting physician stated that the consultation was "very important" in patient management, in clarifying ethical issues, or in learning about medical ethics. We conclude that ethics consultation performed by physician-ethicists provides useful, clinically acceptable assistance in a teaching hospital.

Adult↗

Constraints and heroes.

A story, perhaps apocryphal, is told about the United States surgical team which pioneered the first artificial heart procedure. It is said that the team received a number of telephone calls from people around the country who, worried about the ailing heart recipient, offered to donate to him their own hearts. When the surgical team, justifiably curious, sent psychiatrists to examine these donors, they found to their surprise that many of the donors were rational, competent, sincere, and fully aware that as a consequence of donating their hearts they would die.... My concerns here will be threefold. First, I want to add some substance to the widely-held intuition that there is something morally objectionable about a physician participating in procedures which put even a willing subject at risk. In so doing, I want to explore the larger question of why such a puzzle arises -- why physicians, and many others, find it morally objectionable to help someone do something which all agree to be heroic. Finally, I will start by examining some ways of framing the issue, widely employed in medical ethics, which I believe are simply wrong. This sort of puzzle is much more interesting than proponents of these standard arguments would have us believe, and it illustrates some larger points about morality which are often overlooked.

Altruism↗

Clinical ethics consultations: reasons for optimism, but problems exist.

[The author identifies] five problems familiar to clinical ethicists. (1) Physicians often do not recognize important ethical issues. (2) Debate exists over whether such consultations should give specific management recommendations. (3) Principles of medical ethics cannot, by themselves, resolve real ethical issues. (4) The patient's interests sometimes conflict with the interests of the family, the health professionals, and the hospital. (5) Clinical ethics consultations take a toll on the consultant....[He] discuss[es] the implications of each problem for clinical ethics consultations and offer[s] a solution to it.

Aged↗

Ethics and family practice: some modern dilemmas.

Ethical dilemmas in family practice have increased in frequency and complexity as both the potential benefit and the potential harm of medical treatments have increased. All physicians must be aware of moral issues relating to medicine. Family physicians commonly face ethical problems concerning the patient with diminished autonomy; the right to refuse treatment; allocation of resources; informed consent; surrogate consent (for children, for the incompetent, and for those with diminished autonomy); and the appropriate level of aggressiveness in treatment.

Altruism↗

Can ethnography save the life of medical ethics?

Since its inception contemporary medical ethics has been regarded by many of its practitioners as 'applied ethics', that is, the application of philosophical theories to the moral problems that arise in health care. This 'applied ethics' model of medical ethics is, however, beset with internal and external difficulties. The internal difficulties point out that the model is intrinsically flawed. The external difficulties arise because the model does not fit work in the field. Indeed, the strengths of that work are its highly nuanced, particularized analyses of cases and issues and its appreciation of the circumstances and contexts that generate and structure these cases and issues. A shift away from a theory-driven 'applied ethics' to a more situational, contextual approach to medical ethics opens the way for ethnographic studies of moral problems in health care as well as a conception of moral theory that is more responsive to the empirical dimensions of those problems.

Anthropology, Cultural↗

[Brief remarks on fruitless discussion].

The paper is aimed to show the fruitlessness of the debate on cloning both as regards its theoretical solutions and its practical influence on the final decisions concerning this issue. The author claims that the highly diversified attitudes of the participants of the debate, which issue from their reference to different philosophical approaches and sets of premises, do not allow for development of a commonly accepted theoretical standpoint. However, independently of theoretical controversies, the possibility of cloning human beings and introducing changes in the genotype will probably be accepted due to the similarities between the expected results of genetics and the ideas of contemporary, liberal Western culture.

Bioethical Issues↗

Communication in orthodontic treatment planning: bioethical and informed consent issues.

Orthodontic treatment planning is an interactive process in which the patient or parent and the orthodontist serve as co-decision makers. As in most partnerships, there is a natural tension between the orthodontist and the patient because of differences in their frames of reference. The orthodontist generally is influenced more by the objective findings (the problem list), whereas patients are guided more by subjective issues related to their perceived needs, desires, and values. The art of careful probing and listening to the patient as part of the treatment planning process is an essential skill. One of the most difficult situations in contemporary orthodontics is presented by the patient with a jaw discrepancy for which the alternative treatments are orthodontic camouflage through dental compensation or surgical-orthodontic correction. Computer imaging to simulate the probable treatment outcomes can facilitate communication about these alternatives by eliminating misconceptions. Full disclosure and the consideration of all viable treatment alternatives have great benefits from a risk management standpoint, in addition to their bioethical merits.

Adolescent↗

Genetic profiling of newborns: ethical and social issues.

Identifying genetic factors that could reliably predict health risks for individuals has the potential to bring great health benefits, both for the individuals concerned and for health-care providers. Genetic profiling at birth would allow a person's genome to be analysed at an early stage, and the data electronically stored for future use. However, although this might seem like an attractive proposition, it carries with it serious ethical and social concerns that would need to be addressed if the genetic profiling of newborns were ever to be considered on a population-wide basis.

Bioethical Issues↗

Teaching of medical ethics.

Teaching medical ethics in Manchester within the introductory course of obstetrics and gynaecology is a joint activity with the Centre for Social Ethics and Policy. This interdisciplinary teaching has evolved through lecture sessions with small-group discussions dealing with topics of interest in human reproduction. The small-group discussion have been replaced by an open debate conducted by the students. Their own involvement and participation and an exposure to the disciplines of the humanities has broadened their approach to different ways of problem-solving of these real issues.

Bioethical Issues↗

[Confidentiality, genetic counseling, and public health: a case study on sickle cell trait].

Sickle cell anemia is the most prevalent genetic disease in Brazil. Screening for sickle cell trait in blood donation centers has been recommended by the Brazilian government since 1976. This screening mechanism is one of most common forms of genetic screening for sickle cell disease in the country. This article is based on an ethnographic survey of individuals undergoing genetic counseling in a large blood donation center. The article contends that confidentiality should be a prerequisite for the broad dissemination of genetic information in public health. The ethical principle of confidentiality needs to be seen as a human right and public health issue.

Bioethical Issues↗

Reasonable care? Some comments on Gillett's Reasonable Care.

A discussion of some issues from Grant Gillett's book Reasonable Care. At the metaethical level, Gillett's views about the origin, scope and bindingness of morality are outlined and criticised. Against him it is argued that (a) moral capacity does not follow from linguistic abilitiy, (b) things can matter to non-concept-users and (c) universalisability arguments fail to show that immorality is irrational. At the first order level, Gillett's arguments against surrogacy and euthanasia are answered.

Animal Rights↗