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PubMed2000

Oregon's guidelines for physician-assisted suicide: a legal and ethical analysis.

Oregon's Death with Dignity Act was first passed by a ballot initiative in 1994, but numerous judicial challenges delayed implementation of the Act. In November of 1997, following the United States Supreme Court decisions in Vacco v. Quill and Washington v. Glucksberg, which left the states' power to regulate physician-assisted suicide undisturbed, the Oregon voters upheld their law. Oregon remains the only state in the nation to authorize physician-assisted suicide. The Task Force to Improve the Care of Terminally Ill Oregonians published a Guidebook for health care providers on the Oregon Act, and the New England Journal of Medicine recently issued a special report on the first year's experience under the Act. This paper analyzes the legal context of the Oregon Death with Dignity Act, discusses the efficacy of the tenets in the Guidebook, and explores ethical issues underlying the guidelines, particularly those pertaining to the meaning of a patient's request for assisted suicide and processes supporting informed consent.

Adult↗
PubMed2002

An ethical analysis of cardiopulmonary resuscitation for elders in acute care.

Despite empirical evidence that cardiopulmonary resuscitation (CPR) is of questionable effectiveness in elders with comorbidities, it continues to hold a unique place in the armamentarium of life-sustaining treatments in that consent for CPR is implied and, when needed, is administered emergently. These conditions of implied consent and emergency implementation often preclude an opportunity for patients/surrogates, in conjunction with their nurses and physicians, to determine the appropriateness of the intervention, given the patient's medical and functional status. Healthcare providers who perform CPR on elderly patients often find themselves in morally distressing circumstances because of their anecdotal knowledge of poor outcomes and realization that a multitude of barriers has precluded an anticipatory discussion regarding appropriateness of the treatment. Nurses and other healthcare providers must take the lead in helping patients/surrogates appreciate the meaning of CPR as a life-sustaining intervention and ensure that each patient's situation receives the ethical reflection deserved for each individual as a matter of human dignity.

Advance Directives↗
PubMed2000

An ethical analysis of the mandatory exclusion of immigrants who test HIV-positive.

On 20 September 2000, Canadian newspapers reported that Health Canada recommended to Citizenship and Immigration Canada (CIC) that testing all prospective immigrants for HIV, and excluding those testing positive, constitutes "the lowest health risk course of action." Subsequently, the Minister of Citizenship and Immigration stated that CIC is indeed considering implementing mandatory HIV testing for all prospective immigrants to Canada, and excluding all those testing positive (with the exception of refugees and family-class sponsored immigrants) from immigrating to Canada on both public health and "excessive cost" grounds. This proposal was met with vehement opposition from a broad range of organizations and individuals. In particular, they pointed out that, as stated in the International Guidelines on HIV/AIDS and Human Rights (UNHCHR/UNAIDS, 1998: para 105), "[t]here is no public health rationale for restricting liberty of movement or choice of residence on the ground of HIV status." At the time of going to print, no final decision had been made about whether mandatory HIV testing for all immigrants would be implemented. There are sound ethical, legal, and public policy arguments against imposing mandatory testing and excluding those who test HIV-positive.

AIDS Serodiagnosis↗
PubMedDate not supplied

Hospital-physician relationships in the integrated delivery system: an ethical analysis.

The need to compete for managed care contracts is causing hospitals and physicians to dramatically change how they do business with each other. Most significant is the formation of integrated delivery health-care systems. The emergence of these systems creates an enhanced need for physicians and administrators to better understand what the other actually does. This article examines the new health-care marketplace from both perspectives and how integrated delivery systems affect individual and community patient care, and it offers guidelines for effective hospital-physician relationships within integrated delivery systems.

Cost Control↗
PubMed2003

Will the "secular priests" of bioethics work among the sinners?

In this paper I explore briefly the "secular priesthood" metaphor often applied to bioethicists. I next ask: if, despite our discomfort with the metaphor, we were to embrace the best aspects of the priesthood(s)--which I identify as the missionaries' willingness to work among sinners and lepers, at their own peril--would we be able to live up to that standard of bravery? I then draw a parallel with the fears of contagion currently be voiced (by Carl Elliott and others), with regard to bioethicists working in or near coporate settings. I argue that such fears may themselves have a number of deleterious effects, and I suggest several possible positive steps in response to that fear.

Bioethics↗
PubMed1984

Medical care for elderly patients with diminished competence: an ethical analysis.

The moral responsibilities of physicians caring for elderly patients of diminished or marginal competence are analyzed. In the context of two case studies, it is argued that these responsibilities are not grounded simply in the patient's best interests as the physician understands them. Instead, they should be grounded in the patient's past autonomy, that is, the values and beliefs that the patient held prior to the loss of competence. Family members have a key role to play in assisting the physician to construct this "value history." An important role for the patient's primary care physician is also identified, namely, developing the patient's value history in advance with the patient while he or she is competent, and recording that history in the patient's chart.

Activities of Daily Living↗
PubMed1986

Ethical analysis of the intrapartum management of pregnancy complicated by fetal hydrocephalus with macrocephaly.

The intrapartum management of pregnancy complicated by fetal hydrocephalus with macrocephaly often confronts the physician with a complex array of moral obligations to both mother and fetus that may sometimes come into direct conflict. The authors analyze the component beneficence-based and autonomy-based obligations of these conflicts and offer strategies for resolving them for each of three clinical subgroups. For isolated fetal hydrocephalus, we argue that cesarean section should be performed except when the woman with full informed consent unwaveringly refuses. For fetal hydrocephalus with severe associated abnormalities (those incompatible with postnatal survival or those characterized by the virtual absence of cognitive function), we propose that cephalocentesis followed by vaginal delivery is permissible. For fetal hydrocephalus with other associated abnormalities, we suggest that the permissibility of cephalocentesis followed by vaginal delivery depends on the degree of severity of the associated abnormalities.

Abnormalities, Multiple↗
PubMed1986

Behavior therapy and the elderly: a conceptual and ethical analysis.

This article examines several dimensions of the conceptual framework of the behavioral approach to the treatment of the elderly's problems in living that require emphasis. These dimensions are: 1) Within the behavioral approach behavior is viewed as not being a function of discontinuous, developmental stages each with a unique set of psychological processes; chronological age therefore is considered not to be a causal variable in psychological development, but rather a pure index of only certain physical events; 2) The level of analysis of the behavioral approach to the problems of the elderly is that of molar behavior, and therefore explanations which appeal to other levels of observation, described in different terms and measured in different dimensions, are not considered to be part of this approach; 3) The molar behavior of the elderly is viewed as a function of the contingencies of reinforcement, and behavior that is labeled abnormal is viewed as not quantitatively nor qualitatively different in its development and maintenance from other learned behavior; and 4) Behavior therapy, like all therapies, is a value-laden enterprise in which ends as well as means can be explicated and critically examined. Behavior therapy, in which the involvement of the elderly in the determination of treatment goals is maximized and in which the ability of the elderly to influence and design their environments is enhanced, is advocated.

Aged↗
PubMed1997

Marginally effective medical care: ethical analysis of issues in cardiopulmonary resuscitation (CPR)

Outcomes from cardiopulmonary resuscitation (CPR) remain distressingly poor. Overuse of CPR is attributable to unrealistic expectations, unintended consequences of existing policies and failure to honour patient refusal of CPR. We analyzed the CPR outcomes literature using the bioethical principles of beneficence, non-maleficence, autonomy and justice and developed a proposal for selective use of CPR. Beneficence supports use of CPR when most effective. Non-maleficence argues against performing CPR when the outcomes are harmful or usage inappropriate. Additionally, policies which usurp good clinical judgment and moral responsibility, thereby contributing to inappropriate CPR usage, should be considered maleficent. Autonomy restricts CPR use when refused but cannot create a right to CPR. Justice requires that we define which medical interventions contribute sufficiently to health and happiness that they should be made universally available. This ordering is necessary whether one believes in the utilitarian standard or wishes medical care to be universally available on fairness grounds. Low-yield CPR fails justice criteria. Cardiopulmonary resuscitation should be performed when justified by the extensive outcomes literature; not performed when not desired by the patient or not indicated; and performed infrequently when relatively contraindicated.

Beneficence↗