bluuebunny/crossref_metadata_2025 huggingface dataset:
Depo-Provera--ethical issues in its testing and distribution.
Authors: Potts M , Paxman J M
Published: November 2008

Ethical issues relating to the use of the injectable contraceptive in developed and developing countries alike involve public policy decisions concerning both criteria for testing a new drug and individual choices about using a specific form of contraception approved for national distribution. Drug testing consists of an important but still evolving set of procedures. Depo-Provera is not qualitatively different from any other drug and some unpredictable risks are inevitable, even after extensive animal experiments and clinical trials. In assessing the risks and benefits of Depo-Provera use, epidemiological data from large-scale human use is now beginning to become more important than data from animal experiments and clinical trials. The consumer's best interest is central to any ethically responsible system of drug distribution. Systems of informed choice are needed, even in societies where illiteracy remains common and medical services are weak. In the case of a contraceptive, the risks of non-use leading to unintended pregnancy, which can result in high mortality, are relevant as well as the side-effects of the method. An attempt, therefore, is made here to categorise those issues which are universal and those which are country-specific.
The moral status of embryos.
Authors: Scarlett B F
Published: November 2008

In a recent discussion of human in vitro fertilisation, Kuhse and Singer argue that it is legitimate to destroy unwanted embryos. Their argument fails: it involves at least two and possibly three logical fallacies. If the destruction of embryos is to be justified an alternative argument will have to be found.
Quality of life in cancer patients--an hypothesis.
Authors: Calman K C
Published: November 2008

Quality of life is a difficult concept to define and to measure. An hypothesis is proposed which suggests that the quality of life measures the difference, or the gap, at a particular period of time between the hopes and expectations of the individual and that individual's present experiences. Quality of life can only be described by the individual, and must take into account many aspects of life. The approach is goal-orientated, and one of task analysis. The hypothesis is developed in a diagramatic way, and several methods of testing the hypothesis suggested.
Children in care: are social workers abusing their authority?
Authors: Foster J
Published: November 2008

In reply to Dr Benians's article which suggests that social workers at times abuse their authority, three areas can be considered: the broader context of the social work task, the legal process itself, and the contribution made by child psychiatrists.
Dignity and cost-effectiveness: a rejection of the utilitarian approach to death.
Authors: Brooks S A
Published: November 2008

Utilitarianism is commonly assumed to be the most appropriate sub-structure for medical ethics. This view is challenged. It is suggested that the utilitarian approach to euthanasia works against the patient's individual advantage and is a corrupting influence in the relationship between the physician and society. Dignity for the individual patient is not easily achieved by assessing that person's worth against the yardstick of others' needs and wishes.
Dignity and cost-effectiveness: analysing the responsibility for decisions in medical ethics.
Authors: Robertson G S
Published: November 2008

In the operation of a health care system, defining the limits of medical care is the joint responsibility of many parties including clinicians, patients, philosophers and politicians. It is suggested that changes in the potential for prolonging life make it necessary to give doctors guidance which may have to incorporate certain features of utilitarianism, individualism and patient-autonomy.
Medical ethics: an excuse for inefficiency?
Authors: Mooney G
Published: November 2008

There is frequently an appearance of conflict between medicine and economics. This arises first because the nature of health and health care requires the doctor to make decisions on behalf of the patient and thus serves to explain why medical ethics exist. But secondly it is due to the relative lack of acceptance of the ethics of the common good within medical ethics. As a result while economics in the field of health has as an objective the maximisation of the health of the community, subject to resource constraints, medical ethics pushes individual doctors to try to maximise the health of their patients. There is no reason to believe that the latter will sum to the former. To make the maximisation of health of the community the goal of the medical profession requires institutional changes, particularly with regard to budgeting, which will cajole and if necessary coerce doctors to adopt the good of the community as their objective.
The teaching of medical ethics.
Authors: Smith A
Published: November 2008

Students at Newcastle are exposed to patients during their first week at medical school and attached to a family within the first month. The object is to sensitise them to patients as people rather than vehicles of disease. Medical ethics is introduced as part of the multidisciplinary Human Development, Behaviour and Ageing Course by a lecturer who shows a film which poses an ethical problem. At subsequent tutorials led by the Department of Family and Community Medicine's general practitioner lecturers the subject is discussed as ethical issues arise in the course of their work.
The teaching of medical ethics from a junior doctor's viewpoint.
Authors: Law S A
Published: November 2008

This is a short paper covering my own views on the methods and reasons behind the teaching of medical ethics. All the whys and wherefores are discussed and some conclusions reached. This paper is given from a junior doctor's viewpoint but could equally apply to many others.
Taking blood from children causes no more than minimal harm.
Authors: Smith M
Published: November 2008

The ethical question of whether taking blood from normal children for research purposes is justified, is determined in part at least, by whether or not the children are harmed. To try to assess the risks, the effects of venepuncture on a group of healthy subjects were studied, by means of a parental questionnaire completed approximately eighteen months after the venepuncture had taken place. Ninety-two healthy children aged between 6 and 8 had a blood sample taken for non-therapeutic reasons as part of a research study. Questionnaire responses reveal few negative effects, and in some cases positive effects.
Medical negligence: who sets the standard?
Authors: Norrie K M
Published: November 2008

'The law imposes the duty of care: but the standard of care is a matter of medical judgment'. So says Lord Scarman, outlining the hitherto accepted 'Bolam' standard, in his recent speech in the House of Lords decision of Sidaway v Bethlem Royal Hospital, reflecting earlier judicial dicta suggesting that it is for the medical profession rather than the courts to determine whether or not a medical practitioner has achieved the required standard of care (1). It is suggested here that this concept is bad in principle, and that the weight of judicial authority is against it.
Baby Fae: a beastly business.
Authors: Kushner T , Belliotti R
Published: November 2008

The Baby Fae experiment has highlighted the growing trend in medicine of using animal parts in the treatment of humans. This paper raises the question of the logical and moral justification for these current practices and their proposed expansion. We argue that the Cognitive Capacity Principle establishes morally justified necessary and sufficient conditions for the use of non-human animals in medical treatments and research. Some alternative sources for medical uses are explored as well as some possible programmes for their implementation.
Physicians' strikes--a rejoinder.
Authors: Glick S M
Published: November 2008

The author, a physician, rejects a previous defence of a doctors' strike. There is little justification for strikes in general, still less for doctors' strikes, he claims. Should not doctors rather 'stand above the common herd' and set an example, he asks. Furthermore the whole idea of strikes in which a third and innocent party is deliberately punished in order to apply pressure on someone else is a 'a bizarre ethic indeed' and not to his knowledge justified under any ethical theory.
Dialysis or death? Doctors should stop covering up for an inadequate health service.
Authors: Ward E D
Published: November 2008

Doctors who entered the National Health Service to practice medicine now find themselves forced to practise selection. It seems that patients are being lost at GP level. Surely the basis of a good relationship between doctor and patient relies on trust and trust is based on truth which should not be concealed from patients. And should any one dare decide the quality of life for another human being?
How children can be respected as 'ends' yet still be used as subjects in non-therapeutic research.
Authors: Redmon R B
Published: November 2008

The question of whether or not children may be used as subjects in non-therapeutic research projects has generated a great deal of debate and received answers varying from 'no, never' to 'yes, if societal interests are served'. It has been claimed that a Kantian, deontological ethics would necessarily rule out such research, since valid consent would be impossible. The present paper gives a deontological argument for allowing children to be subjects in certain types of research.
Ethical dilemmas in nursing.
Authors: Wilson-Barnett J
Published: November 2008

Nurses are increasingly realising that they can offer relevant information and participate in decision-making involving ethical issues. However, inter-professional communications are frequently inadequate, and do not permit exchange of opinions. The consequences are often frustrating and upsetting for nurses whose care is affected by others' policies. This paper explores these issues using some clinical examples.
The Warnock Report and single women: what about the children?
Authors: Golombok S , Rust J
Published: November 2008

The Warnock Committee decided not to sanction artificial insemination by donor (AID) and in vitro fertilisation (IVF) for single heterosexual women or for lesbian women on the grounds that it is better for children to be born into a two-parent heterosexual family. From an examination of the effects on children of growing up in fatherless heterosexual and lesbian families, this paper questions that assumption.
Priorities in the allocation of scarce resources.
Authors: Boyd K M , Potter B T
Published: November 2008

The authors report and comment on student reactions to a clinical example of moral choice in the microallocation of scarce resources. Four patients require dialysis simultaneously, but only one kidney machine is available. What moral, as opposed to clinical, criteria are available to determine who should have priority?
Research on human embryos--a justification.
Authors: Brown J
Published: November 2008

The philosophical debate surrounding the moral status of the embryo has reached the public arena. The author of this paper examines some of the common arguments against embryo experimentation, including an influential article by Professor Ian Kennedy. He concludes that these arguments do not succeed in demonstrating that the intentional creation of embryos for research purposes is wrong, unless they also succeed in demonstrating that contemporary liberal abortion laws are also wrong. The author also criticises the conclusions of the Warnock Report, and suggests that the reasons for permitting embryo research must be given a wider public audience.
Ethical map reading in neonatal care.
Authors: Alderson P
Published: November 2008

This paper suggests that medical ethics is often based on assumptions, commonly shared in modern medicine, which can cause problems and which need to be questioned. Two contrasting yet complementary ways of thinking about ethical dilemmas in neonatal care are described as the 'separation' and the 'attachment' approaches. The contribution of medical ethics to the substance and quality of discussions between doctors and parents is considered.
Death with dignity and the right to die: sometimes doctors have a duty to hasten death.
Authors: Miller P J
Published: November 2008

As the single most important experience in the lives of all people, the process and event of death must be handled carefully by the medical community. Twentieth-century advances in life-sustaining technology impose new areas of concern on those who are responsible for dying persons. Physicians and surrogates alike must be ready and willing to decide not to intervene in the dying process, indeed to hasten it, when they see the autonomy and dignity of patients threatened. In addition, the very ways we talk about death and dying need to come under scrutiny, and it is likely that our technical advances should be parallelled by equally arduous advances in the semantic and rhetorical approaches we take to death.
Teaching medical ethics to medical students and GP trainees.
Authors: Boyd K
Published: November 2008

This paper relates two experiences of teaching medical ethics, the first to a small group of clinical medical students, the second to a larger group of GP trainees.
Teaching medical ethics symposium. A student-led approach to teaching.
Authors: Southgate L J , Heard S R , Toon P D , Salkind M R
Published: November 2008

It is increasingly agreed that ethics has a place in undergraduate medical education. There is, however, debate about how it should be taught, and by whom. We present our experience of teaching ethics in a general practice module over six years. During this period there has been a shift from a teacher-centred to a student-centred approach in which students choose ethical issues to explore within a framework provided. The issues raised are discussed with examples, and the future directions of our ethics teaching outlined.
Ethical considerations concerning computers in medicine in the 1980s.
Authors: de Dombal F T
Published: November 2008

The advent of information technology and computers in medicine two decades ago posed a new set of ethical problems. In recent years, these problems have been compounded by the increasing use of computers for supporting clinical decisions as well as administration and record keeping. This presentation considers some of the problems which are raised by the use of computers to support clinical decisions, under the various headings of beneficence, non-maleficence, autonomy and justice. For each aspect the problems raised are described and the implications discussed.
The premature breech: caesarean section or trial of labour?
Authors: Anderson G , Strong C
Published: November 2008

Obstetricians face difficult decisions when the interests of fetus and mother conflict. An example is the problem of choosing the delivery method when labour begins prematurely and the fetus is breech. Vaginal delivery involves risks for the breech fetus of brain damage or death caused by umbilical cord compression and head entrapment. Caesarean section might avoid these dangers but involves risks for the mother, including infection, haemorrhage and even death in a small percentage of cases. If a caesarean section is performed the infant might die anyway, due to complications of prematurity. Thus, decisions about delivery method involve balancing the risks to mother and fetus. Uncertainty about the frequency of fetal injuries in vaginal breech deliveries adds to the difficulty of these decisions.
Ethical dilemmas in pharmacy.
Authors: Lowenthal W
Published: November 2008

Results of surveys in which pharmacy students and pharmacists responded to ethical dilemmas are discussed. Respondents indicated a high level of concern about patient welfare and patient rights in dilemmas involving conflicts with socio-economic issues, and with peers and physicians. Conflicts that might arise as the roles of pharmacists change and the health-care systems evolve are also discussed.
Infanticide for handicapped infants: sometimes it's a metaphysical dispute.
Authors: Long T A
Published: November 2008

Since 1973 the practice of infanticide for some severely handicapped newborns has been receiving more open discussion and defence in the literature on medical ethics. A recent and important argument for the permissibility of infanticide relies crucially on a particular concept of personhood that excludes the theological. This paper attempts to show that the dispute between the proponents of infanticide and their religious opponents cannot be resolved because one side's perspective on the infant is shaped by a metaphysics that is emphatically rejected by the other. In such a situation philosophical argument is powerless to bring about a resolution because there can be no refutation of one side by the other.
Confidentiality: a modified value.
Authors: Emson H E
Published: November 2008

In its original expression as a medical value confidentiality may have been absolute; this concept has become eroded by patient consent, legal actions and change in the climate of public opinion. In particular requirements arising out of legal statutes and common law judgements have greatly modified the confidentiality of the doctor-patient relationship in societies deriving their law from English origins. Despite this, confidentiality remains a value which the physician must strive to preserve. He cannot however do this without considering its effect upon possible innocent third parties.
Teaching clinical medical ethics: a model programme for primary care residency.
Authors: Arnold R M , Forrow L , Wartman S A , Teno J
Published: November 2008

Few residency training programmes explicitly require substantive exposure to issues in medical ethics and fewer still have a formal curriculum in this area. Traditional undergraduate medical ethics courses teach preclinical students to identify ethical issues and analyse them at a theoretical level. Residency training, however, is the ideal time to establish the critical behavioural link which makes ethics truly useful in clinical medicine. The General Internal Medicine Residency Training Program at Rhode Island Hospital has developed an integrated, three-year curriculum with the goals of helping residents to perceive ethical issues in clinical practice, to utilise basic philosophical principles in resolving ethical dilemmas and to communicate these issues clearly and sensitively to patients. The curriculum has been well received by residents and has had a hospital-wide impact. We believe that training residents in medical ethics and communication skills is an effective approach to developing physicians' humane qualities.
Health and disease: what can medicine do for philosophy?
Authors: Scadding J G
Published: November 2008

Philosophical discussions about health and disease often refer to a 'medical model' of bodily disease, in which diseases are regarded as causes of illness; diagnosis consists in identifying the disease affecting the patient, and this determines the appropriate treatment. This view is plausible only for diseases whose cause is known, though even in such instances the disease is the effect on the affected person, and must not be confused with its own cause. But in fact the medical diagnostic process which progresses from recognition of patterns of symptoms and signs, through search for abnormalities of structure and/or function, towards knowledge of causation often stops short of this desirable end-point; and at whatever point it comes to a halt, its result is expressed in terms of 'diseases'. Thus in medical discourse the names of diseases are a convenient device by which the current conclusion of the diagnostic process can be stated briefly; and they have widely varying factual implications. This nominalist analysis of the medical usages of the names of diseases has consequences for definitions of health and disease, and for some problems in medical ethics.
The status of anencephalic babies: should their bodies be used as donor banks?
Authors: Davis A
Published: November 2008

In recent months there has been considerable discussion on the ethics of using organs from anencephalic babies for transplantation purposes. The heart of an anencephalic in Ireland was so used, but the recipient died very soon after the operation. Since this case came to light the Royal College of Physicians has imposed a ban on the use of these babies as donors while a working party investigates the issues involved.* This article attempts to examine the problem and reaches the conclusion that in practice it is not ethical to use the organs of anencephalics for transplants.
Limited autonomy and partnership: professional relationships in health care.
Authors: Wilson-Barnett J
Published: November 2008

Principles of autonomy and self-determination have been upheld as vital to modern-day medical and ethical practice. However, the complexities of current health care and changes in the expectation of some patients and their families justify a review of such concepts. Their limitations and relativities may suggest that other descriptions of partnership and negotiated goal-setting, while based on respect for autonomy, reflect more modern and ideal multi-disciplinary practices. Discussion should extend beyond the 'classic' participants of patient and doctor to a more realistic picture where other health carers are included. It is therefore apposite that other professional relationships are considered as they affect areas of doctors' and patients' responsibilities. Such partnership between members of the team may not be without problems and conflict, but the principle of negotiated agreements could result in more long-term harmony, and greater patient welfare.
Organ donations should not be restricted to relatives.
Authors: Evans M
Published: November 2008

Should we remove whole organs from living donors only in the case where they are genetically related to the intended recipients of such organs? The practice in a majority of European nations is to apply such a restriction. Yet this restriction obviously limits the availability of already scarce donor organs, and curtails the opportunities for altruistic action on the part of those who, in any given case, are not genetically related to the recipient. The author argues that we have a duty to maximise procurement of organs, and that we should respect the 'genetic relative' restriction only in response to compelling moral reasons. The author considers the principal objections to non-related donation and shows them to be misdirected. He concludes that non-related donation should be welcomed where clinically appropriate and truly voluntary.
Priorities in health care: reply to Lewis and Charny.
Authors: Lamb David
Published: November 2008

This paper is a reply to proposals to base priority health-care decisions on public opinion surveys. Whilst it is recognised that current practice is less than satisfactory, it is argued here that basing health-care priorities on societal attitudes in this way is not a solution and does not provide a satisfactory basis for bringing democracy to the health service.
Voluntarism and realism in medieval ethics.
Authors: Haldane J
Published: November 2008

In contrast to other articles in this series on the history of moral philosophy the present essay is not devoted to expounding the views of a single author, or to examining a particular moral theory. Instead it discusses an important dispute between two medieval accounts of the relation between theological and moral propositions. In addition to its historical interest this debate is important both because it connects earlier and later ethical thought--being influenced by Greek moral theories and influencing subsequent European philosophy--and because it concerns issues that remain important to philosophers and to those who claim that their ethical beliefs are dictated by religious convictions.
Psychosocial ethical aspects of AIDS.
Authors: Ross M W
Published: November 2008

The psychosocial morbidity associated with HIV infection and responses to such infection may exceed morbidity associated with medical sequelae of such infection. This paper argues that negative judgements on those with HIV infection or in groups associated with such infection will cause avoidable psychological and social distress. Moral judgements made regarding HIV infection may also harm the common good by promoting conditions which may increase the spread of HIV infection. This paper examines these two lines of argument with regard to the ethical aspects of psychological bases of health care, clinical contact, public perceptions of AIDS and the comparative perspective. It is concluded that the psychosocial aspects of HIV infection impose ethical psychological, as well as medical, obligations to reduce harm and prevent the spread of infection.
The Appleton Consensus: suggested international guidelines for decisions to forego medical treatment.
Authors: Stanley J M
Published: November 2008

Thirty-three physicians, bioethicists, and medical economists from ten different countries met at Lawrence University, Appleton, Wisconsin, to create The Appleton Consensus: International Guidelines for Decisions to Forego Medical Treatment. The guidelines deal with four specific decision-making circumstances: 1. Five guidelines were created for decisions involving competent patients or patients who have executed an advance directive before becoming incompetent, and those guidelines fell into three categories. 2. Thirteen guidelines were created for decisions involving patients who were once competent, but are not now competent, who have not executed an advance directive. 3. Seven guidelines were created for decisions involving patients who are not now and never have been competent, for whom 'no substituted judgement' can be rendered. 4. Eleven guidelines were created for decisions involving the scarcity of medical resources, which exists in all communities. Five concepts were identified as being critical in the establishment of priorities, given the reality of scarce health resources (1). The term 'physician' is used in the American sense, synonymous with 'medical practitioner'.
Brain birth and personal identity.
Authors: Jones D G
Published: November 2008

The concept of brain birth has assumed a position of some significance in discussions on the status of the human embryo and on the point in embryonic development prior to which experimental procedures may be undertaken on human embryos. This paper reviews previous discussions of this concept, which have placed brain birth at various points between 12 days' and 20 weeks' gestation and which have emphasised the symmetry of brain birth and brain death. Major developmental features of brain development are outlined, including the gradualness with which new features generally appear, and also the electroencephalogram (EEG) characteristics of premature infants. From this it is concluded that, if the concept of brain birth is a valid one, it should be placed at 24-28 weeks' gestation. More importantly, it is concluded that the differences between brain development and brain death throw doubt on the concept itself.
The ethical approach to AIDS: a bibliographical review.
Authors: Manuel C , Enel P , Charrel J , Reviron D , Larher M P , Thirion X , Sanmarco J L
Published: November 2008

This bibliographical study involved first the exploitation of four data-banks: Medline, CNRS, Bioethics and AIDS, with the following key words (in conjunction with AIDS): ethics, human rights, confidentiality, legislation, jurisprudence. A total of 412 references were listed between 1983 and the end of 1987. Examination of the quantitative increase of articles over these years shows that, while references to AIDS and/or HIV infection--referred to as 'AIDS' for brevity--increased by about one third per year, the number of papers treating ethical problems linked to AIDS doubled each year. This increase makes it clear that these problems are important and pressing, that they are evolving rapidly and can be given no easy solution. After reading and analysis of accessible articles in readily comprehensible languages, the different themes can be classified in two categories: 1: Measures intended to protect society (starting with the most coercive); quarantine and isolation; discriminatory measures concerning specific groups; non-respect of the confidential nature of medical information; application of the penal code; screening; obligatory declaration and registration; testing of blood given by donors; vaccination and medical innovations, therapeutic assays; information, education. 2. Measures intended to protect the individual: fundamental rights of the patient: his/her right to confidentiality, to information and to treatment; civil rights: civil liberty, right to education, right to work, etc...; rights of the healthy individual: right of those in contact with the patients, safety of hospital staff, of those receiving blood-transfusions, etc... The legislation adopted in the various countries and the main opinions to be found in these articles are listed and analysed, and for each particular theme it is possible to refer to a list of the 232 most important articles. While the debate seems to concentrate on the conflict between the right of society to protect itself against the spread of infection and the 'civil' rights of the infected minorities, our conclusion tends to reduce this antagonism, showing that, particularly as far as the confidential nature of medical information is concerned, measures intended to protect the individual also protect society.
Berkeley's moral philosophy.
Authors: Warnock G
Published: November 2008

Berkeley held that the moral duty of mankind was to obey God's laws; that--since God was a benevolent Creator--the object of His laws must be to promote the welfare and flourishing of mankind; and that, accordingly, humans could identify their moral duties by asking what system of laws for conduct would in fact tend to promote that object. This position--which is akin to that of 'rule' Utilitarianism--is neither unfamiliar nor manifestly untenable. He was surely mistaken, however, in his further supposition that, if this theory were accepted, the resolution of all (or most) particular moral dilemmas would be simple and straightforward.
Choosing between cancer patients.
Authors: Stoll B A
Published: November 2008

The leading ethical problem in medical practice for the coming decade is likely to be how to select patients for priority. Criteria for such decision-making in the case of cancer patients are discussed. Clinicians, ethicists and others need to agree guidelines on giving priority to one patient over another when resources are limited, and such criteria need to be approved by society at large. The public must accept that in a non-explicit rationing system, each individual competes with every other. In the case of even more difficult ethical choices, a multidisciplinary national committee is required to advise on decision-making, and its views need to be debated by the general public.
Prenatal screening in Jewish law.
Authors: Brown J
Published: November 2008

Although prenatal screening is routinely undertaken as part of a woman's antenatal care, the ethics surrounding it are complex. In this paper, the author examines the Jewish position on the permissibility of several tests, including those for Down's syndrome and Tay-Sachs disease, the latter being especially common in the Jewish community. Clearly, the status of the tests depends on whether termination of affected pregnancies is allowed, and contemporary rabbinical authorities are themselves in dispute as to the permissibility of terminating affected pregnancies. The nature of these arguments is examined and the author concludes that there are grounds on which the full range of prenatal screening is permitted in Jewish law.
An obstructed death and medical ethics -- a case conference revisited: commentary 2.
Authors: Higgs Roger
Published: November 2008

The dilemma of whether or not a doctor should tell a patient dying of cancer the truth remains a difficult one, as the disagreement between the two previous writers shows. One favours giving priority to patient autonomy, the other feels the doctor's duty of beneficence should be the overriding principle governing such decisions. To this contributor it seems both approaches have something to offer. By being sensitive to what and how much the patient wishes to know and by learning from the insights provided by the study of medical ethics, doctors can learn how to make better moral decisions in this and in other areas. Both lying and truth-telling carry risks of harm to the patient. Learning to work with and balance these risks is part of clinical practice. So is minimising risks by clear thinking.
Evaluating ethical sensitivity in medical students: using vignettes as an instrument.
Authors: Hébert P , Meslin E M , Dunn E V , Byrne N , Reid S R
Published: November 2008

As a preliminary step to beginning to assess the usefulness of clinical vignettes to measure ethical sensitivity in undergraduate medical students, five clinical vignettes with seven to nine ethical issues each were created. The ethical issues in the vignettes were discussed and outlined by an expert panel. One randomly selected vignette was presented to first, second and third year students at the University of Toronto as part of another examination. The students were asked to list the issues presented by the patient problem. Responses from 281 students were obtained. These students identified an average of 2.72 ethical issues per vignette. Each response was classified under the domains of autonomy, beneficence and justice. Comparisons were made between classes and between vignettes. There was considerable variation between classes and the responses to different vignettes seem to indicate that different vignettes measure the various domains in different ways. It does appear that the use of vignettes is one way to measure aspects of ethical sensitivity in medical students but more study is required to clarify exactly what is being measured.
Institute of Medical Ethics: working party report. HIV infection: the ethics of anonymised testing and of testing pregnant women.
Authors: Boyd K M
Published: November 2008

An Institute of Medical Ethics working party supports the view that explicit permission should normally be sought in the case of testing for HIV antibody. It discusses this in relation to anonymised HIV testing for epidemiological purposes, concluding that this is to be welcomed, given certain safeguards. It next argues that pregnant women may have a greater and more immediate need than others to know their HIV status. It concludes that this need does not justify testing them without their permission, but can be met by voluntary diagnostic testing on an 'opting-out' basis, supported by adequate briefing.
Specialists without spirit: crisis in the nursing profession.
Authors: Hewa S , Hetherington R W
Published: November 2008

This paper examines the crisis in the nursing profession in Western industrial societies in the light of Max Weber's theory of rationalisation. The domination of instrumental rational action in modern industrial societies in evident in the field of modern medicine. The burgeoning mechanistic approach to the human body and health makes modern health care services increasingly devoid of human values. Although the nursing profession has been influenced by various changes that took place in health care during the last few decades (for example greater reliance on technology), the underlying values of the nursing profession still emphasise a broad definition of the well-being of patients. Hence, in recent years the irrational consequences of growing technological medicine in North America has resulted in a serious crisis in the nursing profession. To resolve this crisis the authors propose a reorganisation of modern health care services on the basis of a new paradigm which is compatible with both the health care needs of the people and the main emphasis in education and training of the nursing profession.
Why is preventive medicine exempted from ethical constraints?
Authors: Skrabanek P
Published: November 2008

It is a paradox that medical experimentation on individuals, whether patients or healthy volunteers, is now controlled by strict ethical guidelines, while no such protection exists for whole populations which are subjected to medical interventions in the name of preventive medicine or health promotion. As many such interventions are either of dubious benefit or of uncertain harm-benefit balance, such as mass screening for cancers or for risk factors associated with coronary heart disease, there is no justification for maintaining the ethical vacuum in which preventive medicine finds itself at present.
The ethical use of paradoxical interventions in psychotherapy.
Authors: Foreman D M
Published: November 2008

The purpose of this paper is to establish ethical guidelines for the use of paradoxical interventions in psychotherapy. These are defined as interventions which are counterintuitive, coercive, and which require non-observance by the client. Arguments are developed to show that such interventions are associated with a psychology that understands individuals solely in terms of their relationship: a 'strong interactionist' position. Ethical principles consistent with such a position are considered, and from these it is derived that: paradox is an ethical technique with resistive patients; it requires consent; its content should be consistent with general ethical principles, especially those of beneficence and non-maleficence; non-paradoxical techniques should be preferred when possible; and it should not be used as an assessment procedure. It is concluded that research is needed to explore the effect of such ethical guidelines of effectiveness, though preliminary impressions are encouraging.
Foregoing prehospital care: should ambulance staff always resuscitate?
Authors: Iserson K V
Published: November 2008

Approximately 400,000 people die outside US hospitals or chronic care facilities each year. While there has been some recent movement towards initiating procedures for prehospital Do Not Resuscitate (DNR) orders, the most common situation in the US is that emergency medical systems (EMS) personnel are not authorized to pronounce patients dead, but are required to attempt resuscitation with all of the modalities at their disposal in virtually all patients. It is unfair and probably unrealistic for EMS personnel to have to make a determination of the validity of a non-standard prehospital DNR order (for example, a living will or a durable power of attorney for health care). Existing prehospital DNR protocols range from being very restrictive in the scope of patients allowed to participate and in their implementation, to those that are more liberal. Potential benefits of prehospital DNR orders include freeing up vital personnel and material for use by those who would more fully benefit, and alleviating the enormous emotional strain on patients, families, EMS personnel, and hospital medical staffs involved in unwanted resuscitations that only prolong the dying process. Given this, prehospital DNR orders present several legal and moral problems. These include proper patient identification, the nature of the document itself, precautions incorporated into a DNR system to prevent misuse, potential liability for EMS and hospital personnel, and potential errors in implementation. Functioning prehospital DNR systems need to include: 1) specific legislation detailing the circumstances in which such a document could be used, the wording of such a document, and protection from liability for those implementing the document's directives; 2) having the currently valid document immediately available to the EMS personnel or base station doctors; and 3) acceptable means of identifying the patient. Relatively few US jurisdictions as yet have a prehospital DNR order system, although it is an idea whose time is overdue. Society's imperative to use available technology has pushed us into a situation where a technique to save those with a potential to continue a meaningful and wanted existence is being used indiscriminately to prolong the agony of death.
The Voluntary Euthanasia (Legalization) Bill (1936) revisited.
Authors: Helme T
Published: November 2008

In view of the continuing debate on euthanasia, the restrictions and safeguards which were introduced into the Voluntary Euthanasia (Legislation) Bill 1936 are discussed. Proposals for a new Terminal Care and Euthanasia Bill are suggested, based on some of the principles of the Mental Health Act 1983.
At what level of collective equipoise does a clinical trial become ethical?
Authors: Johnson N , Lilford R J , Brazier W
Published: November 2008

It has often been argued that if a clinician cannot decide which of two treatments to offer, a trial may be ethical, but it is unethical if she/he has a preference. Since individual clinicians usually have a preference, most trials could be judged unethical according to this line of argument. A recent important article in the New England Journal of Medicine argued that individual preferences are not as important as the collective uncertainty of informed clinicians. If clinicians are equally divided, there is a state of collective equipoise and a trial is ethical. However, clinicians will seldom be exactly equally divided. We conducted an ethometric study to find out how much collective equipoise can be disturbed before the potential subjects in a trial think that it is unethical. Half of our subjects perceived a trial as unethical when equipoise was disturbed beyond 70:30. In other words, when 70 per cent of experts favour one treatment, 50 per cent of subjects would prefer that treatment to be administered rather than subjected to critical assessment. When equipoise is disturbed beyond 80:20, less than 3 per cent of subjects would consider human trials morally justifiable.
Telling the truth.
Authors: Jackson J
Published: November 2008

Are doctors and nurses bound by just the same constraints as everyone else in regard to honesty? What, anyway, does honesty require? Telling no lies? Avoiding intentional deception by whatever means? From a utilitarian standpoint lying would seem to be on the same footing as other forms of intentional deception: yielding the same consequences. But utilitarianism fails to explain the wrongness of lying. Doctors and nurses, like everyone else, have a prima facie duty not to lie--but again like everyone else, they are not duty-bound to avoid intentional deception, lying apart; except where it would involve a breach of trust.
The rules of insanity: commentary on: psychopathic disorder: a category mistake?
Authors: Elliott C
Published: November 2008

This paper addresses Colin Holmes's suggestion that the psychopathic disorder is best regarded not as a psychiatric concept, but as an ethical one. The paper argues that the concept of psychopathy, like many other concepts, can span both psychiatry and ethics, and that it is not clear what removing if from the realm of psychiatry would entail. Also, the question of whether the concept of psychopathy is useful for psychiatrists must be separated from the question of whether psychopaths should be exonerated from the moral and legal responsibility for their actions.
Paying for health.
Authors: Black D
Published: November 2008

Health care systems, irrespective of how they are financed, present the paradox that to some observers they appear as a major component of social benefits, while to other observers they seem both excessively costly and limited in their effectiveness. These differing perceptions may be explained in part by the diversity of the determinants of health and disease, only some of which are amenable to those preventive or therapeutic measures encompassed in a health care system--the majority of determinants being genetic, societal, or else uninfluenced by those interventions at present available within a health service. The share of national resources which should be devoted to health care, and the method of raising resources, are primarily matters for political decision; but a national system has advantages both of economy and of comprehensiveness. But when it comes to allocation of resources within the established health budget, the knowledge and skills of health professionals are essential to informed decision-making. The possibilities depend critically on the 'state of the art' at a given time, as is illustrated by the radical changes over time in what could be done for patients with renal failure; and health professionals are likely to be most aware of current options, and of how to choose between them. More speculatively, they are also less likely to confuse the attitudes appropriate to providing a service with those required to run a business.
Autonomy, religious values, and refusal of lifesaving medical treatment.
Authors: Wreen M J
Published: November 2008

The principal question of this paper is: Why are religious values special in refusal of lifesaving medical treatment? This question is approached through a critical examination of a common kind of refusal of treatment case, one involving a rational adult. The central value cited in defence of honouring such a patient's refusal is autonomy. Once autonomy is isolated from other justificatory factors, however, possible cases can be imagined which cast doubt on the great valuational weight assigned it by strong anti-paternalists. This weight is sufficient, in their estimation, to justify honouring the patient's refusal. There is thus a tension between the strong anti-paternalist's commitment to the sufficiency of autonomy and our intuitions respecting such cases. Attempts can be made to relieve this tension, such as arguing that patients aren't really rational in the circumstances envisaged, or that other values, such as privacy or bodily integrity, if added to autonomy, are sufficient to justify an anti-paternalistic stance. All such attempts fail, however. But what does not fail is the addition of religious freedom, freedom respecting a patient's religious beliefs and values. Why religious freedom reduces the tension is then explained, and the specialness of religious beliefs and values examined.
To treat or not to treat: the legal, ethical and therapeutic implications of treatment refusal.
Authors: Wear A N , Brahams D
Published: November 2008

Health professionals faced with refusal of life-saving treatment may wish to override a person's wishes, especially if that person suffers from a mental disorder. Mental illness does not automatically mean a patient is incapable of making decisions of this nature. It is not always clear whether an individual is legally competent to decide whether to undergo treatment or not. This article discusses a clinical example and analyses some of the moral implications.
Involving patients in do not resuscitate (DNR) decisions: an old issue raising its ugly head.
Authors: Loewy E H
Published: November 2008

A recent paper in this journal (1) suggests that involving terminally ill patients in choices concerned with Cardio-Pulmonary Resuscitation (CPR) produces 'psychological pain' and therefore is ill-advised. Such a claim rests on anecdotal observations made by the authors. In this paper I suggest that drawing conclusions in ethics, no less than in science, requires a rigorous framework and cannot be relegated to personal observation of a few cases. The paper concludes by suggesting that patients, if we acknowledge their valid interest in making their own choices, must themselves be allowed to make a prior choice about choosing. Those who may not wish to choose may properly be relieved of this burden and may allow another to choose for them. Routinely allowing others to make choices for competent adults, however, is likely to decrease communication with the dying patient and to introduce an atmosphere of suspicion and fear and to exclude the competent patient from his/her rightful place in the community.