bluuebunny/crossref_metadata_2025 huggingface dataset:
Health, Aging, and Death
Authors: Emson Harry E.
Published: July 2009

In healthcare, it should be a primary requirement that we define accurately what we are trying to do. The necessity for this intensifies when we are under stress, a part of which is caused by increased technological ingenuity outstripping the general ability to pay for it. Dealing with human beings and their problems, we are person and event oriented; our creed has always been and is the best that can be done for an individual, at a point in time. Increasingly, we must modify this traditional approach by viewing episodic care of the individual as a part of two continua, of the individual in relation to their life span, and of the individual in relation to the community and healthcare system to which all belong. We are not skilled or practised in defining our overall aims.
The Limits of Proxy Decision Making: Undertreatment
Authors: Gillick Muriel R. , Fried Terri
Published: July 2009

With the passage by virtually every state legislature of healthcare proxy laws, the medical profession increasingly can expect to rely on the participation of surrogates in making decisions on behalf of incompetent patients. Several concerns about the legitimacy of proxy decision making have been discussed in the ethical and general medical literature: the lack of concordance between the views of patients and their surrogates have been documented on multiple occasions, and cases of abuse by proxies or potential conflict of interest have been reported. Another dilemma that deserves discussion arises when proxies demand withdrawal of treatment that physicians and nurses regard as essential to the wellbeing of the patient. The following case highlights this dilemma.
The Pluralist Constellation
Authors: Parens Erik
Published: July 2009

I work at a research institute where the staff spends its time thinking about ethical issues that arise with progress in medicine, the life sciences, and technology. After such thinking, we make public policy recommendations. We pride ourselves in the diversity of our staff: there is a doctor, a lawyer, a linguistic anthropologist, a political scientist, a theologian, some philosophers, and so on. Both men and women do research and we are religiously diverse: Catholics, Jews, Protestants, and atheists
Information Sharing in Donor Insemination: A Conflict of Rights and Needs
Authors: Daniels Ken R.
Published: July 2009

It is now 110 years since the first reported medical use of donor insemination (DI). Despite its somewhat doubtful beginnings and its chequered history, especially up until the 1970s, DI has become a well accepted and utilised part of most infertility treatment services. An American survey in 1988 reported that approximately 80,000 women a year undergo the procedure, and that over 30,000 children are born each year. The only figures from the United Kingdom cover a 5-month period between August 1 and December 31, 1991, and show that 4,260 patients were treated with DI during this period. The treatment was carried out in 85 different centres.
Reproduction and Rationality
Authors: Jonsen Albert R.
Published: July 2009

Many years ago, the esteemed patriarch of bioethics, Joseph Fletcher, spoke loud and clear in favor of rationality in reproduction. By rationality, he meant not merely limiting population growth, which he certainly favored, but bringing to bear human analytic and creative intelligence on the random and instinctive activities of sexual intercourse and procreation that we share with all mammals. In his 1974 book, The Ethics of Genetic Control: Ending Reproductive Roulette, he foresaw most of the issues that we are facing today. He reflected on artificial insemination, prenatal diagnosis, cloning, eugenics, ectogenesis, ovum transfers, and genetic engineering. He examined these innovations to the extent that he felt that each of them represents a way of exercising rational and responsible control over life and reproduction. The subtitle of his book, “Ending Reproductive Roulette,” proclaims his faith. Dr. Fletcher's dedication to rationality led him to make the astonishing statement, “Man is a maker and the more rationally contrived and deliberate anything is, the more human it is. Therefore, laboratory reproduction is radically human compared to conception by ordinary heterosexual intercourse.”
Informed Consent in the Human Genome Enterprise
Authors: Goldworth Amnon
Published: July 2009

When Jean-Paul Sartre, the French existentialist philosopher, declared some four decades ago that man makes himself, this assertion was based on Sartre's belief that human beings do not possess an essential human nature. Man's self creation had to do with his freedom to choose the roles that he played or could play, and their attendant effects on his attitudes and responsibilities. It said nothing about his freedom to alter his biological nature.
The New Eugenics and Medicalized Reproduction
Authors: Testart Jacques
Published: July 2009

We know today that classical eugenics, of an essentially negative nature, was not only an aggressive and brutal practice but, like its positive counterpart, inefficient as well. In fact, numerous biological, sociological, and psychological events beyond our control arise to prevent the realisation of any eugenic plan. Thus, like all human beings, individuals whose procreation is encouraged by positive eugenics suffer unexpected mutations that are transmitted to their offspring by their gametes. Gene distribution among the gametes at meiosis is the result of an uncontrollable, natural lottery. As an effect of this lottery, positive eugenics could allow the birth of defective babies whereas negative eugenics precludes the birth of normal babies.
Germ-Line Therapy to Cure Mitochondrial Disease: Protocol and Ethics ofIn VitroOvum Nuclear Transplantation
Authors: Rubenstein Donald S. , Thomasma David C. , Schon Eric A. , Zinaman Michael J.
Published: July 2009

The combination of genuine ethical concerns and fear of learning to use germ-line therapy for human disease must now be confronted. Until now, no established techniques were available to perform this treatment on a human. Through an integration of several fields of science and medicine, we have developed a nine step protocol at the germ-line level for the curative treatment of a genetic disease. Our purpose in this paper is to provide the first method to apply germ-line therapy to treat those not yet born, who are destined to have a life threatening, or a severely debilitating genetic disease. We hope this proposal will initiate the process of a thorough analysis from both the scientific and ethical communities. As such, this proposal can be useful for official groups studying the advantages and disadvantages of germ-line therapy.
The Road That I See: Implications of New Reproductive Technologies
Authors: Steel Kathleen O.
Published: July 2009

The prevention of disability has been the driving force behind much research. In epidemiology three levels of prevention are defined: primary, secondary, and tertiary prevention. Primary prevention is the prevention of the initiation or occurrence of a disease; secondary prevention is the prevention or amelioration of the consequences of a disease, and tertiary prevention refers to rehabilitation or the limitation of disability associated with the disease. We have examples of all three levels of prevention in the area of childhood disability. Primary prevention is the protection of infants against congenital rubella syndrome by ensuring that women of childbearing age have adequate immunity before they become pregnant. The prevention of choreoathetosis, mental retardation, and deafness, by treating hyperbilirubinemia and preventing kernicterus in newborns, is a great success story in prevention. Similarly, at the level of secondary prevention, is the reduction in mental retardation caused by phenylketonuria, or PKU, by eliminating phenylalanine in the diets of newborns who lack the enzyme to metabolize this amino acid. Tertiary prevention is the area of rehabilitation medicine, and is regarded as the least desirable level of prevention. Indeed, tertiary prevention can be seen as “doing the best we can” in terms of rehabilitation, often while seeking a means of really preventing the disease.
Compassion, Reason, and Moral Judgment
Authors: Loewy Erich H.
Published: July 2009

This paper will discuss the role of compassion in ethics in general and in healthcare ethics in particular. My thesis is that compassion:

1) as Rousseau pointed out, is a natural trait common to all higher animals (human as well as nonhuman);

2) can and does serve as one of the most important motivators and modulators of ethics in both theoretical and applied aspects;

3) must be controlled by, and in turn control, reason if it is to serve its ethical as well as natural purposes; and

4) as a natural trait has survival value and, by virtue of being a natural trait, cannot be an obligation although there may very well be an obligation to do all that is necessary to nurture and not crush this sentiment.
Sympathy as the Basis of Compassion
Authors: Welie Jos V.M.
Published: July 2009

On one side of his sign board, a nineteenth century surgeon depicted a physician operating on a patient's leg; the other side showed the Good Samaritan taking care of the victim's wounds. Christ's parable has often been quoted and depicted as a primary example of human compassion, to be followed by all persons and,a fortiori, by so-called professionals such as physicians and nurses. If we grant that the parable has not lost its narrative power for 20th century “postmodern” readers living in a “pluralistic” society, it merits a closer analysis.
Illness and Compassion: AIDS in an American Zen Community
Authors: Nakasone Ronald Y.
Published: July 2009

In an interview just before his death, Issan Dorsey, an American Zen priest and abbot of the Hartford Street Zen Center, stated, “AIDS is not fatal. Life is fatal. If you have AIDS, you are alive.” Although infected with AIDS, Issan worked to establish the Maitri Hospice for those dying from complications related to AIDS in the San Francisco Castro District, the heart of the gay and lesbian community. His efforts reflect the statement–although the body may be diseased, one can continue to give abundantly and tirelessly, articulated by Vimalakirti in the Vimalakirtinirdesa Sutra (Sutra on the Teaching of Vimalakirti).
The Human Embryo Research Panel: Lessons for Public Ethics
Authors: Green Ronald M.
Published: July 2009

On the morning of December 2, 1994, after a preceding afternoon of discussion, the Advisory Committee to the Director of the National Institutes of Health (NIH) unanimously voted to approve the recommendations of the Report of the Human Embryo Research Panel. Panel members like myself who were present were elated. The vote marked the culmination of nearly a year of work. Approval of the report also represented a decisive step forward in bringing an end to a 15-year long moratorium on federally funded research on the preimplantation human embryo and techniques ofin vitrofertilization.
Can Communities Protect Autonomy? Ethical Dilemmas in HIV Preventative Drug Trials
Authors: Zion Deborah
Published: July 2009

Before sailing past the sirens' “flowery meadow,” Ulysses instructed his sailors to lash him to the mast so that he would not succumb to the siren's singing. His advance directive demonstrated that he valued his dispositional or long-term autonomy over his unquestioned right to make decisions. He also indicated to his oarsmen that he understood the nature of temptation and his inability to resist it. Ideas of autonomy and sexual choice are central to this discussion of new AIDS treatments, especially the trials of preventative vaccines. Questions arise over the rights of individuals and the extent that these should be limited by concerns of the gay community. Should the gay community intervene in the risky decisions of individuals if no explicit advance directive exists? If so, how do they justify their paternalism? Could their aims not be better served through strengthening the individual dispositional autonomy of trial participants rather than making specific claims about the common good?
The Limits of Proxy Decision Making: Overtreatment
Authors: Fried Terri R. , Gillick Muriel R.
Published: July 2009

Traditionally, surrogates have been involved principally in making decisions about life-sustaining treatment for incompetent individuals. Today, surrogates are increasingly called upon to make everyday medical decisions for patients who are incompetent because they are demented. Some of the potential perils of proxy decision making under these circumstances have been identified, including the lack of concordance between patients and their proxies, demands by proxies for technically futile therapy, and actual abuse of patients. We found a significant number of cases in which healthcare providers at a long-term care facility came into conflict with surrogates because the treatment desired by the surrogate was viewed as excessively burdensome when evaluated by an experienced team of nurses, physicians, and social workers. Neither a court-appointed guardian nor an Institutional ethics committee were likely to be able to resolve these conflicts because of lack of clarity about what constitutes the best Interest of Impaired nursing home patients. The following case illustrates this increasingly common conflict.
Ethics Committees at Work: A Different Kind of “Prisoner's Dilemma”
Authors: Schneiderman Lawrence J. , Jecker Nancy S. , Rozance Christine , Klotzko Arlene Judith , Friedl Birgit
Published: July 2009

A referral was made to our Cardiac Transplant Program for a patient who was in the New Jersey Prison System. The Medical Director of the New Jersey Department of Corrections called regarding a 39-year-old inmate who was being treated in a New Jersey hospital that has a unit for prisoners from a nearby cor- rectional facility. The referring physician described the patient to our Medical Director of heart transplantation as a “murderer” who had been incarcerated since 1987 and sentenced to prison for 30 years without eligibility for parole before completion of his 30-year sentence. The patient was being treated in the CCU of the facility and according to preliminary studies, was suffering from a possible dilated cardiomyopathy. There was evidence of a prior cerebrovascular accident (etiology unknown) with a dense hemiplegia of the left side. The patient was alert but unable to care for himself. There were a number of specific tests necessary to evaluate the patient's candidacy for heart transplantation before actually placing him-on a waiting list. However, the transplant director was uncertain about having the patient brought to our facility for further testing and called some members of the Transplant Selection Committee team to discuss the case.
Encounters With Death
Authors: Bennahum David A.
Published: July 2009

I never saw a dead body until my first anatomy class. Today those who have willed their bodies to science receive letters of gratitude, visit with our students, and have their names put up on memorial plaques; but 37 years ago our subjects were derelicts and anonymous old men found dead in flop house hotels. George C, his name written on a tag tied to one toe, lay stretched out on one of the six dissecting tables in the anatomy laboratory that autumn morning when 1 was 22 and beginning medical school. I remember hesitating at the door and then joining my four partners at Mr. C.'s side, trepidation giving way to curiosity, the moment imprinted forever in my memory by the smell of formalin.
Legalizing Physician-Aided Death
Authors: Capron Alexander M.
Published: July 2009

Physician aid in dying is a broader topic than euthanasia in that the latter usually refers to active euthanasia, while physician assistance also encompasses the issue of assisted suicide. Volumes could be and have been written on physician-assisted death. But my purpose here is to address a specific aspect of the topic: the policy implications with regard to proposed legislation on physician-aided death.

Although the title's reference to physician assistance suggests a focus on the role of the professional, what people often take to be most important and at the heart of the topic is the issue of the patient's rights, usually seen as being manifested in four different ways. First is the right to a dignified death, as free from pain and suffering as possible. In crossing national boundaries and preceding the organization of the professions and the creation of societies, this right is viewed as one that ought to be recognized.
A Middle Ground on Physician-Assisted Suicide
Authors: Tulsky James A. , Alpers Ann , Lo Bernard
Published: July 2009

“[A] murder prosecution is a poor way to design an ethical and moral code for doctors,” observed the California Court of Appeal in 1983. Yet, physicians who have chosen to help terminally ill patients to commit suicide have trespassed on illegal ground. When skilled medical care fails to relieve the pain of terminally ill patients, some people believe that physicians may assist in these suicides. Others reject any kind of physician involvement. The debate on assisted suiczide and active euthanasia has focused on whether these acts can ever be acceptable. We propose to shift the debate to a less divisive issue: whether a caring physician who provides a suffering and ill patient with a prescription for a lethal dose of medication should be prosecuted as a felon. Even assisted suicide's opponents may object to such criminal prosecution. We propose to modify existing criminal laws to give physicians who assist their terminally ill patients in suicide, under carefully defined circumstances, a legal defense against criminal charges.
Living Versus Dying “With Dignity”: A New Perspective on the Euthanasia Debate
Authors: Koch Tom
Published: July 2009

There has been no informed or honest debate in North America over the issue of liberalized euthanasia. Despite thousands of newspaper stories, scores of learned academic articles, a handful of closely analyzed legal decisions, and hours of broadcast news and talk show imagery, a full discussion is yet to begin.
An Analysis of Arguments for and Against Euthanasia and Assisted Suicide: Part One
Authors: Thomasma David C.
Published: July 2009

In advanced technological societies there is growing concern about the prospect of protracted deaths marked by incapacitation, intolerable pain and indignity, and invasion by machines and tubing. Life prolongation for critically ill cancer patients in the United States, for example, literally costs a fortune for very little benefit, typically from $82,845 to $189,339 for an additional year of life. Those who return home after major interventions live on average only 3 more months; the others live out their days in a hospital intensive care unit.
Narratives From The Netherlands
Authors: Dr. C.
Published: July 2009

I graduated from medical school in 1957. I first went into hospital practice for 3½; years, and then went to Africa for 5 years before returning to Holland to resume practicing as a Family Physician. I have also participated in the postgraduate training and education for family doctors in Amsterdam, Currently, there are approximately 2,300 patients in my practice, about average for a Dutch physi- cian. Ten percent of those patients are over the age of 65.
Physician-Assisted Suicide and the Dutch Courts
Authors: Gevers J.K.M.
Published: July 2009

Over the last two decades, Dutch courts have left room for euthanasia (i.e., the deliberate termination of the life of a person on his request by another person). Although a crime under the Penal Code, euthanasia will usually not result in prosecution and conviction if it is committed by a physician according to rules of careful medical practice (including consultation of another physician); if the patient's request is voluntary, well-considered, and enduring; and if there is unacceptable and hopeless suffering and there are no other solutions to the patient's situation.
Euthanasia in The Netherlands: The Role of the Dutch Medical Profession
Authors: Dillmann R.J.M.
Published: July 2009

Is it remarkable that the Royal Dutch Medical Association (RDMA) as a medical professional organization has the point of view that in particular circumstances euthanasia is an acceptable act for a physician. Seen from the viewpoints in the international (medical) community, we might say that it is highly remarkable. Frankly put: the RDMA has met strong international disapproval of its standpoint on euthanasia during the last 10 years or so. For instance, the World Medical Association still condemns physicians performing euthanasia as “unethical.” So far the RDMA is the only professional medical organization that holds the view that in particular cases euthanasia is morally acceptable. However, viewed within the context of Dutch society, the Dutch system of healthcare, and the sociocultural approach to moral questions in The Netherlands, the RDMA point of view ceases to be reprehensible.
Teaching Euthanasia: The Integration of the Practice of Euthanasia Into the Grief, Death, and Dying Curricula of Postgraduate Family Medicine Training
Authors: Kimsma Gerrit K. , van Duin B. J.
Published: July 2009

The open practice of euthanasia in The Netherlands stood alone in the world until the government of the Northern Territories in Australia accepted the possibility of physician-assisted suicide. Even though the active ending of lives in The Netherlands is still a crime by law, the current practice allows it and acquits physicians if certain conditions have been met. Of the many facets of euthanasia, the teaching of this practice represents a further logical step. In this contribution, we intend to describe the comprehensive teaching program of euthanasia of the Free University of Amsterdam's Postgraduate Family Medicine Program. Here students receive university-based training for 1 day a week in a cohort of 12 and on the job training for 4 days with individual family physicians for 2 consecutive years. We especially intend to portray the integration of euthanasia into the wider teaching of the process of counseling and aid of the dying.
The Role of Institutional and Community Based Ethics Committees in the Debate on Euthanasia and Physician-Assisted Suicide
Authors: Schwartz Robert L. , Kushner Thomasine
Published: July 2009

In many countries the debate over the role that physicians may (or should) play in ending life has been limited to the judiciary and other law making institutions, professional medical organizations; and academics. Because of their multidisciplinary and diverse membership, ethics committees may be a particularly appropriate venue through which these discussions can be expanded to include a much larger community. In addition, ethics committees generally act in only advisory capacities because they do not actually make decisions, so they may provide a forum for open discussions in ways that the court and the medical boards (which make licensing determinations) cannot.
Rights of the Terminally Ill Act of the Australian Northern Territory
Authors: Schwartz Robert L.
Published: July 2009

Over the past year the debate over physician-assisted death has been waged in several courts and legislatures, and before at least one electorate as well. Measure 16, the Oregon Death With Dignity initiative that would permit physician-assisted suicide in some circumstances, was approved by the electorate; but it remains on hold while a permanent injunction issued against it by a Federal judge is reviewed by the United States Court of Appeals. Another Federal court judge's decision that the Washington statute criminalizing physician-assisted suicide was unconstitutional when applied to the case of a competent terminally ill patient in intractable pain, was reversed by a three judge panel of that same United States Court of Appeals.
Must Physicians Reveal Their Wounds?
Authors: Furrow Barry R.
Published: July 2009

The physician–patient relationship is anchored in trust. Historically the relationship has been a paternalistic one, with the patient expected to trust the physician's training and skills in doing what is “best” for the patient. But medical knowledge has expanded, as have treatment options and knowledge of the risks of treatment. The physician must now possess volumes of specialized knowledge about procedures and treatments, side effects and alternatives, drugs and their contraindications. Information has become a companion to trust. The patient, while still dependent on the physician's expertise, now wants information about choices and hazards in treatment. Expanded choice has made the patient a consumer of healthcare and its risks rather than a passive recipient of treatment from the professional.
Informed Consent Revisited
Authors: Goldworth Amnon
Published: July 2009

More than three decades after its introduction as a legal requirement for medical treatment in the clinical setting, informed consent continues to be viewed with skepticism as to its need or effectiveness. Some maintain that it is not required because the ordinary individual believes that doctors can be trusted to behave In the best interests of their patients. This issue will be discussed in a later portion of this article. Others are persuaded that informed consent is an unattainable ideal given the limited capacity of the ordinary individual to understand the relevant information. This view is supported by studies intended to show that satisfactory understanding on the part of patients cannot be achieved. In rebuttal, Apple-baum, Lidz, and Meisel observed that:

Such statements are easily refuted by reference to studies of situations in which reasonable comprehension actually has been achieved. A sounder interpretation of all these studies might be that patients and subjects can attain a good level of understanding in many cases, but that several factors — including the manner in which disclosure is made as well as patients' limitations — may get in the way.
Reflections on Non-Heartbeating Organ Donation: How 3 Years of Experience Affected the University of Pittsburgh's Ethics Committee's Actions
Authors: DeVita Michael , Snyder James V. , Fox Renéee C. , Younger Stuart J.
Published: July 2009

In 1991, the University of Pittsburgh Medical Center (UPMC) implemented a policy that permitted the recovery of organs from cadavers pronounced dead using standardized cardiac criteria (Non-Heartbeating Cadavers or NHBC). This policy allowed families that had made a decision to forgo life sustaining treatment to then request organ donation. This entailed taking the patient to the operating room, discontinuing therapy (typically but not necessarily a ventilator), and after the patient is pronounced dead, procuring organs.
Evolving Ethical Issues in Selection of Subjects for Clinical Research
Authors: Weijer Charles
Published: July 2009

Wittgenstein, in his famous critique of philosophy, noted that the influence of an idea can be such that it alters the way that we see the world. “It is like a pair of glasses on our nose through which we see whatever we look at,” he said. “It never occurs to us to take them off.” This view of the power of an idea suggests that the interpretation of an event, and what response this event calls for, can depend upon the view one has of the world. A person who is naive about medical facts may, for example, interpret chest pain upon exertion as a sign that he is “overdoing it”; were he more medically knowledgeable, the same symptom might be interpreted as a possible indicator of coronary artery disease. The naive interpretation calls for rest; the informed interpretation calls for medical attention as well.
For Her Own Good: Protecting (and Neglecting) Women in Research
Authors: Shuster Evelyne
Published: July 2009

In gender mythology woman is nature, the embodiment of life, destruction, and death. Semantically encoded in good and evil, the one conceptual stability woman represents is ambivalence. As a walled garden in which nature works its demonic sorcery, she turns a gob of refuse into a spreading web of sentient being, floating on the snaky umbilical by which she leashes every man. But as an ontological entity, woman is therealFirst Mover. The pregnant woman is devilishly complete. She needs nothing and no one.2 Confronted with the terrible sense of woman's power, man is forced to wrestle with her nature to gain his identity, never to fall back into her. Man is the essential, the norm, the absolute One without reciprocity. Woman is “the Other, posed by the One to define itself, the inessential who never goes back to being the essential and the absolute Other without reciprocity.
Drug Trials, Doctors, and Developing Countries: Toward a Legal Definition of Informed Consent
Authors: Newman Adina M.
Published: July 2009

Assume this hypothetical situation: an American pharmaceutical company, Maxwell Fisch Pharmaceuticals, Inc. (Maxwell), wishes to perform clinical trials involving a new antipsychotic medication, Klezac. Klezac is in its third phase of the clinical stage of the drug research process. Once the testing is complete, Maxwell plans to submit a New Drug Application, the official request to begin marketing Klezac, to the Food and Drug Administration (FDA). The new drug is expected to receive FDA approval in 2 or more years. The company decides to shift its research and development activities to Z, a small, developing country. In doing so, Maxwell is following the course taken by numerous other drug companies who wish to take advantage of faster governmental approval in foreign sites and ensuing cheaper research costs.
Ethics Committees at Work: Physician Experience as a Measure of Competency: Implications for Informed Consent
Authors: Hofmann Paul B. , Nelson William , Cohen Neal , Schwartz Robert L.
Published: July 2009

The following description is based upon an actual case in which a patient initiated legal action after suffering a complication subsequent to an invasive diagnostic procedure performed by a senior fellow. Named as codefendants were the senior fellow, attending physician, and the hospital. Because any hospital with house staff is potentially vulnerable to similar litigation, Ethics Committees at Work is addressing the questions raised by this dilemma.
Justice and the Individual in the Hippocratic Tradition
Authors: Zaner Richard M.
Published: July 2009

Among the many striking features of modern medicine is one that has rarely received its due, save by those specialists in the arcane and remote: medical historians. Medicine is a profoundly historical enterprise, deeply marked by and in continuous, if only implicit, dialogue with its own history. Historical reflection on medicine is therefore an especially compelling undertaking. A case in point: scratch almost any physician today and you find an abiding commitment to “Hippocmtic morality.”
Justice, Society, Physicians and Ethics Committees: Incorporating Ideas of Justice Into Patient Care Decisions
Authors: Loewy Erich H.
Published: July 2009

Issues of social justice have traditionally been given short shrift by American healthcare professionals, feeling that justice at the bedside is inapplicable and possibly even misplaced. However, perhaps motivated by the realization that escalating costs and maldistribution of healthcare represent an intolerable situation, an ever-growing amount of medical literature and healthcare ethics literature is turning to considerations of justice.
Do Physicians' Own Preferences for Life-Sustaining Treatment Influence Their Perceptions of Patients' Preferences? A Second Look
Authors: Schneiderman Lawrence J. , Kaplan Robert M. , Rosenberg Esther , Teetzel Holly
Published: July 2009

Previous studies have documented the fallibility of attempts by surrogates and physicians to act in a substituted judgment capacity and predict end-of-life treatment decisions on behalf of patients. We previously reported that physicians misperceive their patients' preferences and substitute their own preferences for those of their patients with respect to four treatments: cardiopulmonary resuscitation (CPR) in the event of cardiac arrest, ventilator for an indefinite period of time, medical nutrition and hydration for an indefinite period of time, and hospitalization in the event of pneumonia.
Prospective Autonomy and Critical Interests: A Narrative Defense of the Moral Authority of Advance Directives
Authors: Rich Ben A.
Published: July 2009

In the mid to late 1980s a debate arose over the moral and legal authority of advance medical directives. At the center of this debate were two point-counterpoint law journal articles by Rebecca Dresser and Nancy Rhoden. What appeared to have the makings of an ongoing critical dialogue ended with the untimely death of Nancy Rhoden. Rebecca Dresser, however, has continued her challenge of advance directives in numerous publications, most recently in a critique of Ronald Dworkin's Life's Dominion. Like Rhoden, Dworkin has been a staunch advocate of advance directives as an exercise of what has come to be referred to as prospective or precedent autonomy. In this paper I will consider a number of the issues that Dresser has repeatedly raised about the infirmities of advance directives, and suggest that it is from an understanding of and appreciation for the narrative dimension of the life of a person that advanced directives draw one of their most powerful justifications.
Quality Control for Hospitals' Clinical Ethics Services: Proposed Standards
Authors: Leeman Cavin P. , Fletcher John C. , Spencer Edward M. , Fry-Revere Sigrid
Published: July 2009

Hospital ethics committees have become widespread over the last 25 years, stimulated by the Quinlan decision of the New Jersey Supreme Court, the report of a President's Commission, and most recently by the Joint Commission on Accreditation of Health Care Organizations (JCAHO), which now man dates that each hospital seeking accreditation have a functioning process for the consideration of ethical issues in patient care. Laws and regulations in several states require that hospitals establish ethics committees, and some states stipulate that certain types of cases and disputes be taken to such committees. At least one state grants legal immunity to those who implement recommendations of an ethics committee.
Liability of Ethics Consultants: A Case Analysis
Authors: DuVal Gordon
Published: July 2009

The practice of nonphysician ethicist-consultants giving ethics advice concerning the appropriate medical treatment of patients in hospitals is a relatively recent development. Although only a minority of hospitals make substantial use of any formal ethics consulting service, the number is growing and apparently will continue to do so. Indeed, at least among urban teaching hospitals, some sort of ethics consulting service is increasingly commonplace.
Non-Heart-Beating Cadaver Procurement and the Work of Ethics Committees
Authors: Spielman Bethany , Verhulst Steve
Published: July 2009

Recent ethics literature suggests that issues involved in non-heart-beating (NHB) organ procurement are both highly charged and rather urgent. Some fear that NHB is a public relations disaster waiting to happen or that it will create a backlash against organ donation. The purpose of the study described below was to assess ethics committees' current level of involvement in and readiness for addressing the difficult issues that NHB organ retrieval raises—either proactively through policy development or concurrently through ethics consultation.
Ethics without Walls: The Transformation of Ethics Committees in the New Healthcare Environment
Authors: Christensen Kate T. , Tucker Robin
Published: July 2009

As the structure of healthcare delivery undergoes a breathtaking transformation, many ethics committees are wondering how and if they will be affected. Although the impact has not yet been widely felt, hospital-based ethics committees cannot avoid the pressures and upheaval caused by the reorganization of healthcare. This article will briefly review some of the factors contributing to the transformation of medicine, and suggest a number of ways in which ethics committees can respond proactively.
Goldilocks and Mrs. Ilych: A Critical Look at the “Philosophy of Hospice”
Authors: Ackerman Felicia
Published: July 2009

Anyone who thinks contemporary American society is hopelessly contentious and lacking in shared values has probably not been paying attention to the way the popular media portray the hospice movement. Over and over, we are told such things as that “Humane care costs less than high-tech care and is what patients want and need,” that hospices are “the most effective and least expensive route to a dignified death,” that hospice personnel are “heroic,” that their “compassion and dedication seem inexhaustible,” and that “few could argue with the powerful message that it is better [for dying patients] to leave wrapped in the love of family and care givers than locked in the cold, metallic embrace of a machine.“
Reassessing the Reliability of Advance Directives
Authors: May Thomas
Published: July 2009

A competent patient has the right to refuse treatment necessary to sustain life. However, for many end-of-life decisions, we lack direct access to the wishes of a competent patient. Some treatment decisions near the end of life involve patients with severely diminished mental capacity (for example, Alzheimer's patients), some involve patients who are unable to communicate (for example, some stroke victims), and some involve patients who are simply unable or unwilling to participate in decisionmaking due to the nature or severity of their illness.
Teaching the Virtues: Justifications and Recommendations
Authors: Gauthier Candace C.
Published: July 2009

The current interest in and discussion of virtue ethics suggests that this approach to moral decisionmaking has several distinct advantages as applied to ethical issues in healthcare delivery. For the most part, calls to incorporate the virtues of the healthcare provider in discussions of these issues have sought to supplement rather than totally replace traditional ethical theories, such as the utilitarian focus on maximizing the best overall consequences and the Kantian concern to act on the duty of respect for persons. Including virtue-based ethics in such discussions allows for a more eclectic view of what should be considered in resolving difficult moral problems. As many critics of the purely principle-based approach have noted, real moral dilemmas are usually quite messy and are not easily susceptible to satisfactory resolution solely on the basis of abstract moral theories or principles.
Individual Autonomy and Collective Decisionmaking
Authors: Goldworth Amnon
Published: July 2009

Because of the emphasis on individualism and self-governance, medical interventions and medical research in Western nations are preceded by attempts to obtain informed consent from the individual patient or potential research subject. Individual autonomy expresses our belief that persons are ends in themselves and not merely instrumentalities to achieve the goals of others. By respecting the patient or potential research subject in the context of medical decisionmaking, we acknowledge that these individuals are moral agents. Thus, individual autonomy is an important feature of morality as it is practiced in the West. However, there are at least two circumstances in which individual autonomy appears to be threatened. One is embodied in nonwestern societies that favor collective decisionmaking over that of the individual. The other is related to the need for family histories and family testing to determine the susceptibility of family members to some genetically based disease. In both cases, individual judgment appears to be made subordinate to collective judgment.
CQ Interview: Edmund D. Pellegrino on the Future of Bioethics
Authors: Thomasma David C.
Published: July 2009

You wrote an editorial in JAMA giving a 30-year retrospective on bioethics. If you look ahead to the next 30 years, what are the issues you see facing bioethics in the future?
Community Equipoise and the Architecture of Clinical Research
Authors: Karlawish Jason H. T. , Lantos John
Published: July 2009

Equipoise is an essential condition to justify a clinical trial. The term, describes a state of uncertainty: the data suggest but do not prove a drug's safety and efficacy The only way to resolve this uncertainty is further study In many cases, a clinical trial seems to be the most efficient way to prove safety and efficacy Equipoise is therefore not an esoteric philosophic construct applied to research ethics. Rather, since it is vital for the justification of clinical trials, it is part of how society regulates medical progress. Where there is equipoise, drug design and development proceeds according to Food and Drug Administration (FDA) and Health and Human Services (HHS) regulations. When that equipoise ends, a drug is either not approved or becomes standard care.
Just Healthcare beyond Individualism: Challenges for North American Bioethics
Authors: Benatar Solomon R.
Published: July 2009

Medical practitioners have traditionally seen themselves as part of an international community with shared and unifying scientific and ethical goals in the treatment of disease, the promotion of health, and the protection of life. This shared mission is underpinned by explicit acceptance of traditional concepts of medical morality, and by an implied link between individual human rights and the ethics of medical practice long enshrined in a range of World Medical Association (WMA) and other medical codes. These have been powerful instruments exhorting individual practitioners to promote health and to defend universal principles in order to protect their patients and the physician-patient relationship even in the face of authoritarian state coercion and imposed national ideologies and policies. There has been widespread support for this approach and this should be intensified.
Defining the Medical Sphere
Authors: Trappenburg Margo J.
Published: July 2009

Part of the debate on cost containment in healthcare systems may be characterized as applied political philosophy One might say that the current debate between competing theories of justice that started with Rawls'A Theory of Justicein 1971 has acquired a small sister debate in healthcare philosophy Major participants in the debate on social justice have become an important source of inspiration for bioethicists interested in a just distribution of healthcare resources. Thus Rawls'A Theory of Justicehas been remodeled for healthcare philosophy by Norman Daniels. Nozick's libertarian manifestoAnarchy, State, and Utopiahas been used for bioethical purposes by H.T. Engelhardt. The books of Daniel Callahan evidently belong to a family of communitarian theories, though Callahan cannot be said to follow one or another communitarian thinker (be it Christopher Lasch, Alisdair Maclntyre, or Amitai Etzioni) in particular. In the next two sections of this article I will give a very brief sketch of the debate on social justice in political philosophy and then discuss the sister debate on social justice in healthcare.
A Dialogue on Species-Specific Rights: Humans and Animals in Bioethics
Authors: Thomasma David C. , Loewy Erich H.
Published: July 2009

At the end of the most violent century in human history, it is good to take stock of our commitments to human and other life forms, as well as to examine the rights and the duties that might flow from their biological makeup. Professor Thomasma and Professor Loewy have held a long-standing dialogue on whether there are moral differences between animals and humans. This dialogue was occasioned by a presentation Thomasma made some years ago at Loewy's invitation at the University of Illinois, Peoria, Medical Center. During that presentation, Thomasma argued that human beings are sufficiently distinct from other animals genetically and otherwise to justify a moral difference in rights and obligations. In effect, he argued that there are species-specific rights. This essay will pick up the threads of that dialogue.
Readdressing Our Moral Relationship to Nonhuman Creatures: Commentary on “A Dialogue on Species-Specific Rights: Humans and Animals in Bioethics”
Authors: Whitehouse Peter J.
Published: July 2009

Community discourse about the moral status of animals is critical to the future of bioethics and, indeed, to the future of modern society. Thomasma and Loewy are to be commended for sharing thoughts and trying to attain some common ground. I am grateful to them for fostering discussion and allowing me to respond. I cannot endorse the negative tone of the end of their conversation, however. They end with serious concerns about the possibility of any agreement between themselves. Even though I perceive some moral differences between them, I do not believe that they are moral strangers. In this commentary I review the ways in which I agree and disagree with Thomasma and Loewy and conclude with some thoughts about the kind of broad ethical thinking we need to do to address our moral relationship to nonhuman, living creatures.
Japanese Psychiatrists' Attitudes toward Patients Wishing to Die in the General Hospital: A Cultural Perspective
Authors: Berger Douglas , Takahashi Yoshitomo , Fukunishi Isao , Hosaka Takashi , O'Dowd Mary Alice , Ono Yutaka , Kuboki Tomifusa , Ishikawa Yoshihiro
Published: July 2009

In 1961 in Japan, the son of a hospitalized man suffering from severe pain after a stroke mixed a cup of milk with insecticide and arranged for his unsuspecting mother to give this to the patient, who had requested that his son assist him in dying. The son could not endure his father's condition and killed him in order to show his love.
Prevalence of increased nuchal translucency in fetuses with congenital cardiac disease and a normal karyotype
Authors: Vogel Melanie , Sharland Gurleen K. , McElhinney Doff B. , Zidere Vita , Simpson John M. , Miller Owen I. , Allan Lindsey D.
Published: July 2009

Objectives

Our aims were to estimate the prevalence of increased nuchal translucency in fetuses with a normal karyotype that were subsequently diagnosed with congenital cardiac disease on fetal echocardiography, and to assess whether there is a link between increased nuchal translucency and specific congenital cardiac malformations.

Methods

We reviewed all patients referred to King’s College Hospital and the Evelina Children’s Hospital in London for fetal echocardiography between January 1998 and December 2007. We investigated the proportion of chromosomally normal fetuses with congenitally malformed hearts in which nuchal thickness was increased, both overall and with specific defects.

Results

We indentified 2133 fetuses with congenital cardiac disease by prenatal echocardiography. Of those, 707 were excluded due to abnormal karyotype, and 690 were excluded due to unknown karyotype. The remaining 736 were eligible for inclusion. Among 481 fetuses with documented congenital cardiac disease and normal chromosomes, making up 23% of the overall cohort, 224 had increased nuchal thickness defined as equal or greater than 2.5 millimetres, this being 0.47 of the inclusive cohort, with 95% confidence intervals from 0.42 to 0.51. These proportions were significantly higher than the expected proportion of the normal population, which was 0.05 (p < 0.001). The only diagnosis for which the proportion of fetuses with nuchal translucency measurement equal or greater than 2.5 millimetres was higher than the others was atrioventricular septal defect, with 0.62 of this cohort having abnormal values, with 95% confidence intervals from 0.47 to 0.77 (p = 0.038).

Conclusion

We found that nearly half of prenatally diagnosed fetuses with congenitally malformed hearts, when examined ultrasonically in the first or early-second trimester, had increased nuchal thickness. We recommend, therefore, referral of all fetuses with increased nuchal translucency for fetal echocardiography.