bluuebunny/crossref_metadata_2025 huggingface dataset:
Technical expertise as an ethical form: towards an ethics of distance.
Authors: Girard M
Published: November 2008

The present article proceeds from the observation that the therapeutic relationship is basically unequal. This inequality essentially concerns the respective situation of the patient and his or her doctor vis-à-vis medical knowledge. A strict professionalism guarantees that this inequality remains factual and without essential value. Yet, if both partners unreflectively allow affectivity excessively to intrude into their relationship, their behaviour may then be inspired by subconscious, rather than rational, motives. In that case, the unverifiable allegations of philanthropy or paternalism may be used to rationalise a kind of 'medical sadism' which attempts to justify the will to humiliate the patient by means of the constraints inherent in medical care. The concept of ethical form is introduced as a non-verbal criterion of ethical reliability. It is mainly a way of training the will through the application of rationally justified rules of behaviour. In this context, it is suggested that an effort to remain constantly within the limits of professionalism represents a method of training for the achievement of some degree of ethical credibility in the therapeutic relationship. In the long term, such abstinence could constitute a sort of catharsis, and thereby help to reveal the non-rational motives in medical behaviour. Contrary to the belief prevailing in modern society, the established limits of medical knowledge are not so broad. The application of these limits would probably be the best method of preventing emotions from interfering undesirably in the therapeutic relationship.
Handicapped infants: medical ethics and the law.
Authors: Raphael D D
Published: November 2008

The main purpose of this paper (1) is to draw attention to a gap between the principles of Common Law and the principles accepted by many leading medical practitioners on the ethics of allowing severely handicapped infants to die. The Common Law principles are shown in Court of Appeal judgements on two cases. The contrasting principles of many paediatricians were illustrated at the trial of Dr Leonard Arthur. The paper suggests that the gap could be closed by statutory guidance on general principles. It also argues that utilitarian concepts misrepresent the ethical issues of medical dilemmas like this one.
For whom the bells knell.
Authors: Heim M , Steinbach T
Published: November 2008

A 72-year-old widowed woman known to have an organic brain syndrome was hospitalised owing to gangrene of her lower limbs. The gangrene had been caused by an adduction contracture of her hip resulting in pressure on the medial surface of her left leg. In addition she had pressure sores over both trochanters and the sacrum. The smell of putrefication could be sensed from a distance and on examination large white worms could be seen slithering in the decomposing tissue. The patient was pyrexial, oblivious of her surroundings, and without pain. Surgery--limb amputations--would not restore the patient to a cognitive state nor improve here quality of life, but abstinence posed an inherent threat of sepsis, and revulsion to the attendants. The sacral pressure sore was so large that surgical closure was impossible. The question of surgical intervention is discussed.
Biological processes and moral events.
Authors: Buckle S
Published: November 2008

It is often argued that the continuity of the processes of embryo development precludes the establishment of morally significant boundaries, once development is under way. These arguments typically claim that marking out any moral boundaries requires identifying particular significant events, and that in such circumstances this is either impossible or arbitrary. In this paper it is argued that arguments of this kind are not cogent. The paper concludes by indicating where the real problems lie.
Is AIDS a just punishment?
Authors: Murphy T F
Published: November 2008

There are religious and philosophical versions of the thesis that AIDS is a punishment for homosexual behaviour. It is argued here that the religious version is seriously incomplete. Because of this incompleteness and because of the indeterminacies that ordinarily attend religious argumentation, it is concluded that the claim may be set aside as unconvincing. Homosexual behaviour is then judged for its morality against utilitarian, deontological, and natural law theories of ethics. It is argued that such behaviour involves no impediment to important moral goals and is not therefore immoral. Where natural law might be used to condemn homosexual behaviour, it is argued that the theory itself is not well established. Consequently there is a prima facie reason for rejecting the philosophical version of the punishment thesis. This conclusion is further supported by noting the lack of proportion between the purported immorality of homosexuality and a punishment as devastating as AIDS.
Philosophy, medicine and its technologies.
Authors: Almond B
Published: November 2008

There is a need to bring ethics and medical practice closer together, despite the risk and problems this may involve. Deontological ethics may promote sanctity of life considerations against the quality of life considerations favoured by consequentialists or utilitarians; while talk of respect for life and the value of life may point to more qualified ethical positions. This paper argues for a respect-for-life position, dismissing a utilitarian cost-benefit outlook as too simplistic; but an unqualified fixed principles approach is also ruled out, both because of its unacceptable consequences in individual cases and also because of its reliance on the slippery slope argument which, it is argued, is logically and psychologically deficient. The case of genetic engineering provides an example in which the notion of respect may operate, but in which broad general principles also apply. A cautious conservatism towards accepted principles is recommended in the development of medical technologies.
Psychiatry and the death penalty.
Authors: Kastrup M
Published: November 2008

Mentally ill people are not to be judged by the same rules as the mentally fit. Prisoners evaluated medically unfit for execution must undergo psychiatric treatment until their mental health is restored. Psychiatrists are placed in an ethical dilemma when asked to judge the mental health of prisoners on death row. A high prevalence of psychiatric and neurological disorders are reported on death row. Health professionals have an important role in implementing codes of ethics prohibiting any involvement in the execution process. Resolutions have already been passed by several associations including the World Medical Association, the American Psychiatric Association and Nordic medical associations.
The autonomy of demented patients: interviews with caregivers.
Authors: Ekman S L , Norberg A
Published: November 2008

Tape-recorded semi-structured interviews were conducted with 21 nursing aides and enrolled nurses in the geriatric clinic in Umeå, Sweden. The interviews focused on the difference between the care of demented and non-demented patients and ethical conflicts in dementia care. The results indicate that caregivers have problems in providing the demented patients with opportunities to act autonomously in everyday matters on the ward, mainly due to the difficulty of understanding what the patients wish and the fact that their wishes, when understood, often seem irrational. Measures to provide the demented patients with more opportunities to act autonomously in everyday matters are suggested.
Ethics of cancer management from the patient's perspective.
Authors: Jolley M G
Published: November 2008

The face of cancer treatment is changing and the patient is both living longer and is increasingly able to articulate the problems of painful illness and look for solutions to problems which cannot be solved by technological advances. The cancer patient, like others, is looking towards the self-help movement to help him achieve a better quality of life. The doctor-patient relationship can be improved for both by a franker look at the present situation, the needs of the patient, the family, and those without family, especially in relation to cancer and its cultural connotations. Self-help groups provide the support so often lacking in cancer management (including continuity), and a peer group within which adjustment needed to bring about the change in lifestyle required is achieved. Death need not be a word which is taboo, nor cancer a word which means Death. This is useful for doctor and patient alike.
Ethical aspects of genetic disease and genetic counselling.
Authors: West R
Published: November 2008

With the reduction in diseases due to nutritional deficiencies and infection, disorders which are wholly or partly genetic are becoming relatively more important in all branches of modern medicine. Genetic counselling has developed in recent years from just explaining to an individual or a couple the risk of them producing a handicapped child, to the possibility in many cases of better diagnosis and active intervention to reduce the risks. At the same time antenatal screening programmes have been introduced to detect women who may be carrying a fetus with a severe handicapping anomaly. The ethical aspects of these advances are considered in this article. A practical approach to the resolution of any dilemmas is proposed which concentrates on the duties incumbent on doctors and other health care workers involved with patients who have or may carry genetic disorders.
The moral philosophy of Maimonides.
Authors: Broadie A
Published: November 2008

Maimonides (1135-1204) wrote extensively on moral philosophical matters. In his three main works, the Commentary on the Mishnah, the Mishneh Torah, and the Guide of the Perplexed, he developed a far-reaching ethical system which is Aristotelian and yet is also greatly dependent upon the Rabbinic tradition. In this paper it is argued that Maimonides presents an effective synthesis of these apparently disparate traditions.
Suffer the little children some autonomy.
Authors: Wachenje V
Published: November 2008

There exist layers of disparity between perspectives and perceptions of handicap or disability. Handicap is frequently seen by the able-bodied (and minded), as a condition unrelated to themselves. Learned articles appear in specialist journals, but lost in the relentless tidal wave of words, is the very real personality of that handicapped individual ... not waving, but drowning.
The importance of listening to medical students' experiences when teaching them medical ethics.
Authors: Osborne L W , Martin C M
Published: November 2008

This paper describes the change of emphasis that occurred in the teaching of ethics to small groups of clinical students. Although the original focus of the course was on the analysis of ethical dilemmas associated with individual patients known to the students, it soon became evident that there were, for the students themselves, more fundamental ethical dilemmas in their new role as clinical students. These included worries about how to respond when patients asked questions which their consultants had previously deceived them about, worries about inflicting pain on patients, as with intravenous cannulation, and the role of the medical student in the clinical team. We emphasise the need to explore student experiences as part of the process of ethics teaching.
The ethics of general practice and advertising.
Authors: Colman R D
Published: November 2008

UK general practitioners (GPs) are self-employed entrepreneurs running small businesses with commercial considerations. In this situation there is no clear distinction between information, self-promotion and advertising. In response to the growing public demand for more information about medical services, the medical profession should voluntarily accept the notion of soft self-promotion in the form of 'notices' or 'announcements' placed in newspapers. Newspapers are the most effective way of giving easy access to information. The resistance to newspapers may be more concerned with preserving certain medical traditions than consideration of the public interest. The General Medical Council's (GMC's) arguments against soft self-promotion are seen as misguided paternalism, inconsistent and irrational.
Informed consent and moral integrity.
Authors: Gillett G R
Published: November 2008

Informed consent is required for any medical procedure although the situations in which it is given are beset by uncertainties and indeterminacies. These make medicolegal scrutiny of such situations very difficult. Although some people find the decision in the Sidaway case incomprehensible because of its continuing regard for a 'professional practice standard' in informed consent, I will argue that an important fact in many cases is the moral integrity of the doctor concerned and the pattern of his practice. This may provide the only morally principled and legally accessible evidence enabling a correct decision to be made in a difficult case. Although the epistemological significance of a professional practice standard is thereby defended the 'prudent patient standard' for what counts as consent is left intact.
QALYs: are they enough? A health economist's perspective.
Authors: Mooney G
Published: November 2008

John Rawles's criticism of QALYs are seen as being both imprecise and largely unhelpful. This paper accepts that there are problems in both QALYs themselves and in the current decision-making processes with which they seek to help. The QALY pliers tend to play down the former and the QALY knockers the latter. It is suggested that theories (regret theory and prospect theory) other than expected utility theory, which is normally seen as the basis for QALYs, may provide better approaches to measuring health service outputs. Thus equity, information and decision-making per se are not handled as well in the expected utility QALYs as they could be. Developing better QALYs, with qualifications, is the goal.
The student with a writing block--the ethics of psychotherapy.
Authors: Bloch S
Published: November 2008

The potential role of the psychotherapist as ethical interventionist is considered with reference to a patient who presented with a writing block. The case for the therapist to act paternalistically is followed by the counterargument which revolves around the respect for autonomy. A bridge between these two opposing positions is then offered which depends on viewing informed consent as a dynamic process. As part of this procedure it is made clear that while autonomy is the desired end-state of psychotherapy, it is not the be all and end all of treatment. Therapy is necessarily value-laden since it aims for the enhancement of the patient's state of autonomy; it is value-free inasmuch as the therapist desists from guiding the patient in how she should live her life.
The future prospects for living wills.
Authors: Greaves D
Published: November 2008

Following the first enactment of living will legislation in California in 1976 the majority of the states of the USA have now passed similar laws. However, flaws have been identified in the way they work in practice and many states are considering reviewing their legislation. In Britain there is no legislation but the subject is currently commanding considerable interest. This paper assesses the future prospects for living wills in both the USA and Britain, analysing the different options available and comparing the two countries. If patients who become permanently incompetent are to have their previous autonomous decision-making respected, there is general agreement that advance directives for health care must be introduced. The difficulty is in deciding how to implement them, and especially whether this should be by statutory or non-statutory means, the traditions in the two countries being very different in this respect. It is concluded that whichever route is taken, promoting respect for patient autonomy is as much a matter for education and persuasion of doctors as of the adoption of particular instruments. Doctors should therefore be trained in what constitutes good medical practice in this area and, to ensure that it can be carried out properly, the general level of medical facilities for these patients must also be protected and promoted.
A vote for no confidence.
Authors: Warwick Sarah Jane
Published: November 2008

This paper considers the justifications for adhering to a principle of confidentiality within medical practice. These are found to derive chiefly from respect for individual autonomy, the doctor/patient contract, and social utility. It is suggested that these will benefit more certainly if secrecy is rejected and the principle of confidentiality is removed from the area of health care.
Do not resuscitate decisions: discussions with patients.
Authors: Schade S G , Muslin H
Published: November 2008

The problem of psychological pain caused by discussions of do not resuscitate status with patients is addressed. Case histories of patients with such distress are given. We propose that not all patients should be informed of their do not resuscitate status, that the information about such status be given incrementally, and that the giving of further information be guided by the patient's reaction to earlier information. While some affirm the duty of the physician always to inform the patient about his or her do not resuscitate status, we affirm the duty of the physician to determine whether the patient wishes to enter into this discussion.
Pregnancy in a severely mentally handicapped adult.
Authors: O'Hara J
Published: November 2008

What happens when we discover that a severely mentally handicapped girl, resident under our care, is heavily pregnant? What options are open to us in her management? What are the legal and ethical issues involved? How do we ensure that she receives the best possible care and protection and will the involvement of the police actually make the situation worse? Few of us have had the experience of working through such dilemmas, and little help can be found in consulting 'experts' who are awaiting the result of 'test cases' in the High Courts. This article highlights some of the problems we encountered with such a case.
Advanced medical ethics symposia for fifth-year students.
Authors: Grant V J
Published: November 2008

Case-based, multidisciplinary seminars provided a vehicle for clinicians, philosophers and students to debate current problems in medical ethics in a manner which ensured maximum learning and interest for all participants. Prior training in philosophical medical ethics was an essential prerequisite, giving students the knowledge and skills to take part in the discussions at an appropriate level of sophistication.
An obstructed death and medical ethics.
Authors: Dunbar S
Published: November 2008

In this case analysis deception or lying to a dying patient is discussed within the context of different relationships: the relationship between the patient and her family doctor, the relationship between the patient and the surgeon and the relationship between the patient and her family. It is suggested that the principle of veracity is not only a core feature in the patient-doctor relationship but is also fundamentally connected with the basic element of trust between the patient and doctor. The surgeon, in deceiving the patient, even at the request of her husband, betrayed her trust in violating the principle of veracity. The primary responsibility of the surgeon was towards his patient rather than her family. In lying to his patient the surgeon failed to give Mrs Fasper something she needed most: respect for her as a person.
Resource allocation: a plea for a touch of realism.
Authors: Whitaker P
Published: November 2008

The problem of resource allocation in health has stimulated much thought and research, in attempts to provide objective, rational methods by which necessary choices can be made. One such method was proposed in a paper in this journal. The authors argued for a utilitarian approach, which they claimed to demonstrate was acceptable to society at large. This paper argues that the evidence supporting such a claim was flawed; such a utilitarian approach is not socially acceptable, and is therefore not relevant. Rather more relevant directions for research are discussed, based on the assertion that a degree of realism is essential when considering the problems of resource allocation.
A plea for a touch of realism: reply to P Whitaker
Authors: Lamb David
Published: November 2008

This reply to P Whitaker's `Resource allocation: a plea for a touch of realism' acknowledges that health-care ethics should be relevant to events in the real world, but questions the extent to which philosophical inquiry should be confined to parameters determined by existing sociopolitical forces.

The reading of the daily paper is the morning prayer of the realist.
A national committee for the ethics of research.
Authors: Gelder M G
Published: November 2008

A National Committee for the Ethics of Research could consider new questions arising from innovations in research or practice, deal with multi-centre trials, adjudicate when separate local committees give conflicting advice about similar projects, or oversee the work of district committees. The value of each of these functions is assessed and it is concluded that a national committee would be most valuable in providing detailed evaluations of difficult or controversial issues. Though it could offer useful advice about multi-centre trials, local committees would probably wish to continue to consider research involving patients within their health districts even though approval had been given by a central committee. A national committee could usefully oversee the working of a system of quality control throughout the country, but the detailed monitoring of district committees would be done more effectively at regional level.
Review of the teaching of medical ethics in London medical schools.
Authors: Burling S J , Lumley J S , McCarthy L S , Mytton J A , Nolan J A , Sissou P , Williams D G , Wright L J
Published: November 2008

The study examined the influence of the Pond Report on the teaching of medical ethics in the London medical schools. A questionnaire was given to both medical students and college officers. All medical colleges reported that ethics was included in the curriculum. However, from students' replies, it seems that attendance of optional courses is low and that not all current final year medical students have had any formal teaching in medical ethics. Stronger guidelines are necessary to ensure appropriate ethical training in London medical schools.
The echo of Nuremberg: Nazi data and ethics.
Authors: Post S G
Published: November 2008

Over the past two years, debate about the use of data taken from Nazi concentration camp experiments has intensified. Many survivors of the Holocaust have been particularly offended at the publication of hypothermia or other data. This article argues against the use of unethically obtained data, and considers the debate from the perspective of the rights of Holocaust victims.
Death in Denmark: a reply.
Authors: Lamb D
Published: November 2008

This reply to Martyn Evans's support for a cardiac-centered concept of death attempts to meet some objections to the brainstem definition of death. Evans's appeal to Wittgenstein's philosophy is also criticised.
Ethics and embryos.
Authors: Poplawski N , Gillett G
Published: November 2008

In this paper we argue that the human form should be seen to exist, in a longitudinal way, throughout the continuum of human growth and development. This entails that the moral value of that form, which we link analytically to the adult, interacting, social and rational being, attaches to all phases of human life to some extent. Having established this we discuss the consequences it has for the moral status of the human embryo. We then apply this argument, and the resulting moral status, to the area of reproductive technology. In doing this we show that there are certain regulations and controls which ought to apply to the use of these infertility treatments.
Psychopathic disorder: a category mistake?
Authors: Holmes C A
Published: November 2008

Although the concept of psychopathy retains its currency in British psychiatry, apparently being meaningful as well as useful to practitioners (1), it is often taken to refer to a purely legal category with social control functions rather than a medical diagnosis with treatment implications. I wish, in this brief article, to suggest that it is essentially, and most usefully, an ethical category which stands outside the diagnostic framework of present-day psychiatry.
Medical records: practicalities and principles of patient possession.
Authors: Gilhooly M L , McGhee S M
Published: November 2008

This review of issues and research is in two parts: 1) practical problems surrounding patient-held records and 2) ethical arguments for and against patient-held records. We argue that research on patient-held records indicates that there are no substantial practical drawbacks and considerable ethical benefits to be derived from giving patients custody of their medical records.
Section 47--assault on or protection of the freedom of the individual? A short response to Greaves.
Authors: Gray J A
Published: November 2008

Section 47 of the 1948 National Assistance Act allows incompetent people, usually old people, to be removed from their homes. It can be considered as a repressive tool, designed to infringe personal liberty, but in this article it is argued that it can also be considered as being legislation which governs and controls professional practice and protects the old person from public prejudice.
Alternative medicine: methinks the doctor protests too much and incidentally befuddles the debate.
Authors: Pietroni P C
Published: November 2008

Dr Kottow in his paper Classical medicine v alternative medical practices (1) places the alternative/orthodox medicine debate within an historical context of anti-quackery literature. My paper explores the nature of science as it is applied to clinical practice and challenges the narrow view of the diagnostic process as outlined by Dr Kottow. Research methodologies more appropriate to 'whole person' medicine are suggested as having more ethical value than those based on the clinical trial.
A proposal to classify happiness as a psychiatric disorder.
Authors: Bentall R P
Published: November 2008

It is proposed that happiness be classified as a psychiatric disorder and be included in future editions of the major diagnostic manuals under the new name: major affective disorder, pleasant type. In a review of the relevant literature it is shown that happiness is statistically abnormal, consists of a discrete cluster of symptoms, is associated with a range of cognitive abnormalities, and probably reflects the abnormal functioning of the central nervous system. One possible objection to this proposal remains--that happiness is not negatively valued. However, this objection is dismissed as scientifically irrelevant.
In the genes or in the stars? Children's competence to consent.
Authors: Alderson P
Published: November 2008

Children's competence to refuse or consent to medical treatment or surgery tends to be discussed in terms of the child's ability or maturity. This paper argues that the social context also powerfully influences the child's capacity to consent. Inner attributes and external influences are discussed using an analogy of the genes and the stars.
Baby marrow: ethicists and privacy.
Authors: Zucker A
Published: November 2008

A family had a child in large part to use its marrow in the hopes of saving the life of an older child afflicted with leukaemia. Public response from medical ethicists was negative. This paper argues that what the family did was not clearly wrong and that the ethicists should not have made public pronouncements calling the morals of the family into question.
'Aid-in-dying' and the taking of human life.
Authors: Campbell C S
Published: November 2008

In several US states, the legalisation of euthanasia has become a question for voters to decide in public referenda. This democratic approach in politics is consistent with notions of personal autonomy in medicine, but the right of choice does not mean all choices are morally equal. A presumption against the taking of human life is embedded in the formative moral traditions of society; human life does not have absolute value, but we do and should impose a strict burden of justification for exceptions to the presumption, as exemplified by the moral criteria invoked to justify self-defence, capital punishment, or just war. These criteria can illuminate whether another exception should be carved out for doctor-assisted suicide or active euthanasia. It does not seem, in the United States at any rate, that all possible alternatives to affirm the control and dignity of the dying patient and to relieve pain and suffering, short of taking life, have been exhausted. Moreover, the procedural safeguards built into many proposals for legalised euthanasia would likely be undone by the sorry state of the US health care system, with its lack of universal access to care, chronic cost-containment ills, a litigious climate, and socioeconomic barriers to care. There remains, however, common ground in the quest for humane care of the dying.
Legislation on euthanasia: recent developments in The Netherlands.
Authors: Gevers J K
Published: November 2008

Recently, new developments took place in the Dutch debate on the legislation of euthanasia. After a brief account of that debate, the article discusses a new government proposal for legislation in this field, which was submitted to the Dutch parliament in November 1991. This proposal relates not only to euthanasia but also to some other medical decisions concerning the end of life. The author concludes that, for several reasons, it is unsatisfactory.
After bioethics and towards virtue?
Authors: Toon P D
Published: November 2008

The place of philosophical medical ethics in medical education and clinical practice has recently been questioned. Although partially valid, the criticisms do not warrant abandoning the enterprise. Instead a reappraised model, based on Aristotelean concepts of intellectual and moral virtue is suggested.
The disposal of the aborted fetus--new guidelines: ethical considerations in the debate in Sweden.
Authors: Kallenberg K , Forslin L , Westerborn O
Published: November 2008

During the 70s and 80s ethical debate concerning the fetus became intensive. The great advances made in medical technology and research and improvements in prenatal diagnosis as well as in embryological research have led us to believe that the fetus is an individual with recognised claims to protection. In Sweden the aborted fetus has previously been considered merely as a risk-disposal problem, equivalent to dangerous and infected material and there have been no specific guidelines for the treatment of the fetus after abortion. In July 1990 treatment of aborted fetuses was changed with the general guidelines from the National Board of Health and Welfare. The present paper sets out the main contents of the guidelines and discusses the gradually changing views concerning the status of the human fetus in Sweden, as well as the public debate which has been a contributing factor to these changes.
Medical ethics in the European Community.
Authors: Riis P
Published: November 2008

Increasing European co-operation must take place in many areas, including medical ethics. Against the background of common cultural norms and pluralistic variation within political traditions, religion and lifestyles, Europe will have to converge towards unity within the field of medical ethics. This article examines how such convergence might develop with respect to four major areas: European research ethics committees, democratic health systems, the human genome project and rules for stopping futile treatments.
Resuscitation and senility: a study of patients' opinions.
Authors: Robertson G S
Published: November 2008

In the context of 'Do-not-resuscitate' (DNR) decisions, there is a lack of information in the UK on the opinions of patients and prospective patients. Written anonymous responses to questionnaires issued to 322 out-patient subjects showed that 97 per cent would opt for cardiopulmonary resuscitation (CPR) in their current state of health. In the hypothetical circumstance of having advanced senile dementia only 10 per cent would definitely want CPR, with 75 per cent preferring not to have CPR. There were no significant correlations between the responses and sex or age. Of 270 patients asked verbally if they found the questions disturbing, none said they did. These findings show that the great majority of patients would not wish CPR if severely senile, and that patients are not disturbed by questions relating to their choice for or against CPR. This should encourage further investigations of patients' opinions on CPR in a broader range of conditions, and greater use of DNR orders.
Altruism towards the end of life.
Authors: Davies J
Published: November 2008

In the author's experience most normal healthy adults would like to have the choice of medical help to die if they become incurably ill and find their suffering intolerable. The reasons for this are explored, based on ten years of listening and talking about the subject to a wide variety of people in many countries. The most familiar and common are the avoidance of futile suffering and the desire to retain autonomy. This paper concentrates on the dislike of losing independence and its closely associated wish to continue to behave altruistically. Some reasons for the general lack of recognition of the last two are suggested.
The Polkinghorne Report on Fetal Research: nice recommendations, shame about the reasoning.
Authors: Keown J
Published: November 2008

In 1989, in the wake of the first operations to transplant fetal tissue into the brains of sufferers from Parkinson's Disease, the UK Code of Practice governing the use of the fetus for research was overhauled by an eminent committee under the chairmanship of the Reverend Dr John Polkinghorne. The Polkinghorne Report has, however, attracted remarkably little comment or analysis. This paper is believed to be the first to subject it to sustained ethical and legal scrutiny. The author concludes that, although the committee's recommendations meet the major objections to the Code of Practice, the report is nevertheless vulnerable to criticism in its treatment of at least three issues: the moral status of the fetus; paternal consent to fetal use, and the ethical inter-relation of fetal use and abortion.
Medical futility, treatment withdrawal and the persistent vegetative state.
Authors: Mitchell K R , Kerridge I H , Lovat T J
Published: November 2008

Why do we persist in the relentless pursuit of artificial nourishment and other treatments to maintain a permanently unconscious existence? In facing the future, if not the present world-wide reality of a huge number of persistent vegetative state (PVS) patients, will they be treated because of our ethical commitment to their humanity, or because of an ethical paralysis in the face of biotechnical progress? The PVS patient is cut off from the normal patterns of human connection and communication, with a life unlike other forms of human existence. Why the struggle to justify ending a life which, it is said, has suffered an irreversible loss of the content of consciousness? Elsewhere, the authors have addressed the ethical controversies and confusion engendered by ambiguous terminology, misuse of medical facts and the differing interpretations of what constitutes 'effective' treatment: in particular, the issue of whether in fact artificial nutrition and hydration is a medical treatment, or simply part of the obligatory care owed to all patients, permanently unconscious or not. In this paper, we intend to argue that recent analyses of medical futility, its meaning and ethical implications, despite an absence of public consensus, permit some tentative re-evaluation of our ethical obligations to the PVS patient.
Postmortem procedures in the emergency department: using the recently dead to practise and teach.
Authors: Iserson K V
Published: November 2008

In generations past, it was common practice for doctors to learn lifesaving technical skills on patients who had recently died. But this practice has lately been criticised on religious, legal, and ethical grounds, and has fallen into disuse in many hospitals and emergency departments. This paper uses four questions to resolve whether doctors in emergency departments should practise and teach non-invasive and minimally invasive procedures on the newly dead: Is it ethically and legally permissible to practise and teach non-invasive and minimally invasive procedures on the newly dead emergency-department patient? What are the alternatives or possible consequences of not practising non-invasive and minimally invasive procedures on newly dead patients? Is consent from relatives required? Should doctors in emergency departments allow or even encourage this use of newly dead patients?
The ethics of medical involvement in torture: commentary
Authors: Hare R M
Published: November 2008

Torture does need to be defined if we are to know exactly what we are seeking to ban; but no single definition will do, because there are many possible ones, and we may want to treat different practices that might be called torture differently. Compare the case of homicide; we do not want to punish manslaughter as severely as murder, and may not want to punish killing in self-defence at all. There are degrees of torture as of murder. Unclarities simply play into the hands of would-be torturers.

Downie is unsuccessful in deriving the duty of doctors not to be involved in torture from an analysis of the word `doctor'. It may be contrary to the role-duty of doctors to participate in torture; but there might be other duties which overrode this role-duty. The right approach is to ask what principles for the conduct of doctors have the highest acceptance-utility, or, as Kant might have equivalently put it, what the impartial furtherance of everyone's ends demands. This approach yields the result that torture (suitably defined) should be banned absolutely. It also yields prescriptions for the conduct of doctors where, in spite of them, torture is taking place.
The great slippery-slope argument.
Authors: Burgess J A
Published: November 2008

Whenever some form of beneficent killing--for example, voluntary euthanasia--is advocated, the proposal is greeted with a flood of slippery-slope arguments warning of the dangers of a Nazi-style slide into genocide. This paper is an attempt systematically to evaluate arguments of this kind. Although there are slippery-slope arguments that are sound and convincing, typical formulations of the Nazi-invoking argument are found to be seriously deficient both in logical rigour and in the social history and psychology required as a scholarly underpinning. As an antidote, an attempt is made both to identify some of the likely causes of genocide and to isolate some of the more modest but legitimate fears that lie behind slippery-slope arguments of this kind.
The ethics of experimental heroin maintenance.
Authors: Ostini R , Bammer G , Dance P R , Goodin R E
Published: November 2008

In response to widespread concern about illegal drug use and the associated risk of the spread of HIV/AIDS, a study was undertaken to examine whether it was, in principle, feasible to conduct a trial providing heroin to dependent users in a controlled manner. Such a trial involves real ethical issues which are examined in this paper. The general issues examined are: should a trial be an experiment or an exercise in public policy?; acts and omissions; countermobilization; termination of a trial, and payment for drugs and for a trial. The specific issues examined are: selection of trial participants; privacy; issues for staff working on a trial; coupling the trial with other treatment, and issues for researchers. A number of alternative approaches to the various ethical issues are presented and discussed.
Deciding not to resuscitate in Dutch hospitals.
Authors: van Delden J J , van der Maas P J , Pijnenborg L , Looman C W
Published: November 2008

The use of do not resuscitate (DNR) orders in Dutch hospitals was studied as part of a nationwide study on medical decisions concerning the end of life. DNR decisions are made in 6 per cent of all admissions, and 61 per cent of all in-hospital deaths were preceded by a DNR decision. We found that in only 14 per cent of the cases had the patients been involved in the DNR decision (32 per cent of competent patients). The concept of futility is analysed as these findings are discussed. We conclude that determining the effectiveness of resuscitation is a medical judgement whereas determining the proportionality (burden/benefit ratio) of it requires a discussion between doctor and patient (or his or her surrogates). Since the respondents in the cases without patient involvement gave many reasons for their decision that went beyond determining effectiveness, we conclude that more patient involvement would have been desirable.
The place of medicine in the American prison: ethical issues in the treatment of offenders.
Authors: Sissons P L
Published: November 2008

In Britain doctors and others concerned with the treatment of offenders in prison may consult the Butler Report (see Focus, pp 157) and specialist journals, but these sources are concerned with the system in Britain only. In America the situation is different, both in organization and in certain attitudes. Dr Peter L Sissons has therefore provided a companion article to that of Dr Paul Bowden (page 163) describing the various medical issues in prisons. The main difference between the treatment of offenders in prisons in America and in Britain lies in the nature of the federal system which means that each state may operate a different system in a variety of prisons and prison medical services are as various. Nationally, the prison systems are 'structured to treat and cure the offender'. Therefore it follows that the prison medical officer is only one of the professionals concerned with this 'cure' of the offender. This principle also applies to any form of research: medical research in prisons is part of a programme which covers a wide field of social and judicial research. The prison medical officer (where there is one) has of course to look after sick prisoners, and the American idea of 'cure' is also expressed in the need for more corrective surgery where, for example, it is necessary to remove physical impediments to social rehabilitation. But a doctor is only found on the staff of those institutions which are large: in the smaller prisons there may be only first-aid facilities, and no specially appointed doctor in the community. Moreover medicines are often dispensed by medical auxiliaries who are sometimes prisoners themselves. Finally, in America prisoners are regularly invited to volunteer as subjects for medical and social research for which they are paid. In short, although it is hoped to 'cure' a prisoner he is a criminal first and a patient second.
The just provision of health care: a reply to Elizabeth Telfer.
Authors: Steiner H
Published: November 2008

Dr Hillel Steiner in this reply to Elizabeth Telfer takes each of her arguments for different arrangements of a health service and examines them--'four positions which can be located on a linear ideological spectrum'--and adds a fifth which could have the effect of 'turning the alleged linear spectrum into a circle'. Underlying both Elizabeth Telfer's article and Dr Steiner's reply, the base is inescapably a 'political' one, but cannot be abandoned in favour of purely philosophical concepts. Whatever the attitude of mind of the reader of these two papers to the provision of a health service, the stimulus to more careful assessments of our own National Health Service and its problems can only be good.
The case for a statutory 'definition of death'.
Authors: Skegg P D
Published: November 2008

Karen Quinlan, the American girl who has lain in deep coma for many months, is still 'alive', that is to say, her heart is still beating and brain death has not occurred. However, several other cases have raised difficult issues about the time of death. Dr Skegg argues that there is a case for a legal definition of death enshrined in statutory form. He suggests that many of the objections to a statutory provision on death are misplaced, and that a statute concerning the occurrence of death could remove all doubts in the minds of both doctors and public as to whether a 'beating heart cadaver' was dead or alive for legal purposes.
Confidentiality and the law.
Authors: McConnell T
Published: November 2008

Codes of medical ethics issued by professional organizations typically contain statements affirming the importance of confidentiality between patients and health-care practitioners. Seldom, however, is the confidentiality obligation depicted as absolute. Instead, exceptions are noted, the most common of which is that health-care professionals are justified in breaching the confidence of a patient if required by law to do so. Reasons that might be given to support this exception are critically discussed in this paper. The conclusion argued for is that this is not a legitimate exception to the confidentiality rule.
The task of nursing ethics.
Authors: Melia K M
Published: November 2008

This paper raises the questions: 'What do we expect from nursing ethics?' and 'Is the literature of nursing ethics any different from that of medical ethics?' It is suggested that rather than develop nursing ethics as a separate field writers in nursing ethics should take a lead in making the patient the central focus of health care ethics. The case is made for empirical work in health care ethics and it is suggested that a good way of setting about this is to ask practising nurses about the real ethical problems they encounter.
The favoured child?
Authors: Jones D , Dickenson D , Devereux J
Published: November 2008

This case conference concerns a child who has been in care following a diagnosis of emotional abuse and a serious incident of physical abuse. She wants to return home again, and her parents, who had previously scapegoated her, now blame the family's previous ills on her sister instead. The Children Act 1989 gives considerable weight to the child's wishes, but what if the child returns home and is re-abused? In this case conference a child psychiatrist, a philosopher and a lawyer discuss the issues of clinicians' responsibilities, moral luck, and child care law.
Consequences for patients of health care professionals' conscientious actions: the ban on abortions in South Australia.
Authors: Cannold L
Published: November 2008

The legitimacy of the refusal of South Australian nurses to care for second trimester abortion patients on grounds of conscience is examined as a test case for a theory of permissible limits on the autonomy of health care professionals. In cases of health care professional (HCP) conscientious refusal, it is argued that a balance be struck between the HCPs' claims to autonomous action and the consequences to them of having their autonomous action restricted, and the entitlement of patients to care and the consequences for them of being refused such care. Conscientious action that results in the disruption or termination of health care services, however, is always impermissible on two grounds. Firstly, because it is at this point that the action '... invades a patient's autonomy, puts a patient at serious risk ... [and] treats a patient unjustly' (1) Secondly, because the consequences of such refusals turn them into political acts--acts of civil disobedience. It is arguable that in order for acts of civil disobedience to be legitimate, certain obligations are required of the dissenter by the community. It is concluded that the actions of the South Australian nurses, which have over the last few years both terminated and disrupted second trimester services, are morally impermissible.