bluuebunny/crossref_metadata_2025 huggingface dataset:
The principle of QALY maximisation as the basis for allocating health care resources.
Authors: Cubbon J
Published: November 2008

This paper presents a case for allocating health care resources so as to maximise Quality Adjusted Life Years (QALYs). Throughout parallels are drawn with the grounds for adopting utilitarianism. QALYs are desirable because they are essential for human flourishing and goal-attainment. In conditions of scarcity the principle of QALY maximisation may involve unequal treatment of different groups of people; and it is argued that this is not objectionable. Doctors in their dealings with patients should not be continually consulting the principle (though it can sometimes be useful); instead by following existing ethical codes more QALYs will be produced overall. In the formulation of policy, however, the principle should be applied in a thoroughgoing way and, if it is, it will not have some of the counterintuitive consequences it may have in interpersonal situations.
Can compulsory removal ever be justified for adults who are mentally competent?
Authors: Greaves D A
Published: November 2008

Section 47 of the National Assistance Act is controversial in that it makes provision for the compulsory removal and care of mentally competent adults in certain limited circumstances. A case is described in which it is argued that compulsory management could be justified. This is because the diversity and potentially conflicting nature of the relevant considerations involved in this and a restricted range of other cases, defies their being captured in any wholly rational moral scheme. It follows that if the law is to be both sensitive and just it cannot always provide definitive guidance as to how the community doctor, as the designated decision-maker, should act. The acceptance of his or her judgement is therefore necessary and depends for its proper working on trust, which can only be gained through compassion and respect for the patients concerned.
Consent in paediatrics: a complex teaching assignment.
Authors: Grant V J
Published: November 2008

The topic of consent in paediatrics is made more difficult, and at the same time more interesting, by the complexity of the issues involved and the consequent diversity of viewpoints. In a teaching session for senior medical students on consent in paediatrics it proved necessary to reinstate previous learning from a range of disciplines. Philosophical medical ethics, developmental psychology, communication skills and the appropriate legal definitions all contributed to a proper understanding of the cases presented. The two most important additional components appeared to be a) a basic knowledge of cognitive development and how to apply it, and b) an awareness of the need to balance an individual child's rights or best interests, with those of the family unit, as well as the wider society.
Classical medicine v alternative medical practices.
Authors: Kottow M H
Published: November 2008

Classical medicine operates in a climate of rational discourse, scientific knowledge accretion and the acceptance of ethical standards that regulate its activities. Criticism has centred on the excessive technological emphasis of modern medicine and on its social strategy aimed at defending exclusiveness and the privileges of professional status. Alternative therapeutic approaches have taken advantage of the eroded public image of medicine, offering treatments based on holistic philosophies that stress the non-rational, non-technical and non-scientific approach to the unwell, disregarding traditional diagnostic categories and concentrating on enhancing subjective comfort and well-being, but remaining oblivious to the organic substrate of disease. This leads to questionable ethics in terms of false hopes and lost opportunities for effective therapy.
The reversibility of death.
Authors: Cole D J
Published: November 2008

The ordinary concept of death is analysed and compared with revisionary medical definitions, especially those based on irreversible loss of brain function. Prior critics of revisionary definitions have focused on the locus, the brain; I am concerned with the irreversibility condition. I argue that 1) the irreversibility condition is ambiguous, 2) it has unacceptable epistemic and other consequences on any plausible construal, and 3) irreversibility is not part of the ordinary concept of death. I conclude that recent medical definitions seek illegitimately to obtain the certainty of a weak construal of 'irreversible' along with the freedom from moral obligation of the strong construal.
Ethics and ethics committees: HIV serosurveillance in Scotland.
Authors: Tappin D M , Cockburn F
Published: November 2008

Knowledge of the heterosexual spread of HIV is needed to plan future health-care needs. In December 1989 we gained approval and finance for unlinked anonymous testing of neonatal Guthrie card samples in Scotland. Local ethics committee approval was required before testing could start. Twenty ethics committees were approached in the 15 Scottish health board areas. Nineteen of the committees have agreed, representing 99.6 per cent of births in Scotland. Our method of contacting ethics committees is discussed, as are the points raised.
Cost-effectiveness analysis: is it ethical?
Authors: Williams A
Published: November 2008

Many clinicians believe that allowing costs to influence clinical decisions is unethical. They are mistaken in this belief, because it cannot be ethical to ignore the adverse consequences upon others of the decisions you make, which is what 'costs' represent. There are, however, some important ethical issues in deciding what costs to count, and how to count them. But these dilemmas are equally strong with respect to what benefits to count and how to count them, some of which expose ethically untenable assumptions about such widely-used clinical criteria as survival rates. One of the advantages of systematic cost-effectiveness analysis is that it exposes these hidden assumptions, and requires explicit judgements to be made about which ethical position is appropriate in a particular policy context. This should have the important incidental benefit of improving the accountability of policy-makers to the community they are serving.
The impact of physician denial upon patient autonomy and well-being.
Authors: Meyers C
Published: November 2008

It is now widely accepted that a patient's ability to engage in autonomous decision-making can be seriously threatened when she denies significant aspects of her medical condition. In this paper I use a true case to reveal the harmful effects of physician denial upon patient autonomy and well-being. I suggest further that such physician denial may be more common than is generally acknowledged, since aspects of the contemporary medical ethos likely serve to reinforce rather than to undercut such denial.
Learning to see: moral growth during medical training.
Authors: Andre J
Published: November 2008

During medical training students and residents reconstruct their view of the world. Patients become bodies; both the faults and the virtues of the medical profession become exaggerated. This reconstruction has moral relevance: it is in part a moral blindness. The pain of medical training, together with its narrowness, contributes substantially to these faulty reconstructions. Possible improvements include teaching more social science, selecting chief residents and faculty for their attitudes, helping students acquire communication skills, and helping them deal with their own pain. Most importantly, clearer moral vision requires time and scope for reflection.
Stress.
Authors: Charlton B G
Published: November 2008

'Stress' is a widely used word in clinical practice, the biological sciences and everyday life; but one which has little real value, serving mainly to confuse and confound rational thought. Whether it is described in terms of stimulus, response, or a combination of the two the definitions of stress are invariably found to be circular. We should stop using the word 'stress' and instead discuss specific stimuli or responses as appropriate. The author suggests that 'pressure' and 'tension' might provide suitable substitutes for everyday clinical practice.
Is the endoscopic view too narrow?
Authors: Neal T J , Krasner N
Published: November 2008

Palliative laser therapy for gastrointestinal tumors is now well established. Its use however may be associated with complications not directly attributable to the laser therapy. These complications potentially decrease the quality of life which opposes the aim of treatment.
Ethical dilemmas in malaria drug and vaccine trials: a bioethical perspective.
Authors: Barry M , Molyneux M
Published: November 2008

Malaria is a disease of developing countries whose local health services do not have the time, resources or personnel to mount studies of drugs or vaccines without the collaboration and technology of western investigators. This investigative collaboration requires a unique bridging of cultural differences with respect to human investigation. The following debate, sponsored by The Institute of Medicine and The American Society of Tropical Medicine and Hygiene, raises questions concerning the conduct of trans-cultural clinical malaria research. Specific questions are raised about the difficulties of informed consent in different cultural settings and whether there is any role for community involvement. Discussants debate whether drug and vaccine trials not approved in an industrialised country are ever defensible if performed in a third-world setting. Potential conflicting priorities between investigators are discussed and ideas regarding conflict resolution are offered.
Epidemiology and moral philosophy.
Authors: Westrin C G , Nilstun T , Smedby B , Haglund B
Published: November 2008

To an increasing extent ethical controversies affect and sometimes obstruct public health work and epidemiological research. In order to improve communication between the concerned parties a model for identification and analysis of ethical conflicts in individual-based research has been worked out in co-operation between epidemiologists and moral philosophers. The model has two dimensions. One dimension specifies relevant ethical principles (as beneficence, non-maleficence, autonomy and justice). The other dimension specifies the groups of persons involved in the conflict under consideration (for example: the study-population, individuals who may benefit from the results, the researchers and their personnel, the community at large). The model has been applied to the problem of legitimacy of case-register research and to problems in psychiatric health services research as well as epidemiological research.
Let's keep metaphysics out of medical ethics: a critique of Poplawski and Gillett.
Authors: Leavitt F J
Published: November 2008

I argue that the concept of 'longitudinal form', which Poplawski and Gillett have introduced into ethical discussions about embryos and gametes, involves too many metaphysical subtleties to be a useful aid to making moral decisions. I conclude by suggesting a criterion for relevance in medical ethics.
The European Convention on bioethics.
Authors: Byk C
Published: November 2008

Benefiting from a widely recognised experience of the field of bioethics, the Council of Europe which represents all the democratic countries of Europe, has embarked on the ambitious task of drafting a European Convention on bioethics. The purpose of this text is to set out fundamental values, such as respect for human dignity, free informed consent and non-commercialisation of the human body. In addition to this task, protocols will provide specific standards for the different fields concerned with the application of biomedical sciences. The convention and the first two protocols (human experiments and organ transplants) are due to be ready for signature by mid 1994.
Response to Roger W. Hunt.
Authors: Callahan Daniel
Published: November 2008

A response to a critique by Roger W. Hunt of my views on the eventual likely need to use age as a standard for the allocation of expensive, high-technology, life-extending medical care for the elderly. The response encompasses three elements: 1. that while the elderly have a substantial claim to publicly-provided health care, it cannot be an unlimited claim; 2. that a health care system which provided a decent, coherent set of medical and social services for the elderly would be sufficient, even if some limits had to be set; and 3. allocation and rationing decisions should not be made by individual doctors at the bedside but by regional or national policy.
Response to: What counts as success in genetic counselling?
Authors: Clarke Angus
Published: November 2008

Clinical genetics encompasses a wider range of activities than discussion of reproductive risks and options. Hence, it is possible for a clinical geneticist to reduce suffering associated with genetic disease without aiming to reduce the birth incidence of such diseases. Simple cost-benefit analyses of genetic-screening programmes are unacceptable; more sophisticated analyses of this type have been devised but entail internal inconsistencies and do not seem to result in changed clinical practice. The secondary effects of screening programmes must be assessed before they can be properly evaluated, including the inadvertent diagnosis of unsought conditions, and the wider social effects of the programmes on those with mental handicap. This has implications for the range of prenatal tests that should be made available. While autonomy must be fully respected, it cannot itself constitute a goal of clinical genetics. The evaluation of these services requires interdepartmental comparisons of workload, and quality judgements of clients and peers.
On discontinuing dialysis.
Authors: Wight J
Published: November 2008

Ethical issues relating to the withdrawal of dialysis are discussed, comparing dialysis with other life-support systems, particularly artificial ventilation. It is argued that there is no ethical difference between discontinuing treatment in each case. One practical difference between the two is that patients with chronic renal failure are less likely to have reduced autonomy, and so can engage in discussions with their doctors regarding the situations in which their life-supporting treatment might be discontinued. It is argued that doctors caring for patients on dialysis have an ethical duty to discuss with these patients the circumstances in which they may wish to discontinue dialysis.
Maturity of children to consent to medical research: the babysitter test.
Authors: Koren G , Carmeli D B , Carmeli Y S , Haslam R
Published: November 2008

The age of maturity of children to consent for medical research is under debate, as different authorities regard the capacity of young teenagers as either satisfactory or not to grant consent without parental participation in the process. The present paper contrasts the generally accepted guideline for ethics in paediatric research in Canada with what the same children are allowed and expected to be able to do as babysitters. This comparison reveals deep incongruences in the way the maturity of the same children is appreciated for two different tasks.
A randomized trial of ethics education for medical house officers.
Authors: Sulmasy D P , Geller G , Levine D M , Faden R R
Published: November 2008

We report the results of a randomized trial to assess the impact of an innovative ethics curriculum on the knowledge and confidence of 85 medical house officers in a university hospital programme, as well as their responses to a simulated clinical case. Twenty-five per cent of the house officers received a lecture series (Limited Intervention or LI), 25 per cent received lectures and case conferences, with an ethicist in attendance (Extensive Intervention or EI), and 50 per cent served as controls. A post-intervention questionnaire was administered. Knowledge scores did not differ among the groups. Confidence regarding ethical issues was significantly greater in the aggregate intervention group (3.9 on a 1 to 5 scale) compared to the control group (3.6). Confidence regarding procedural issues related to ethics was significantly higher for the EI group than for the controls (4.0 v 2.8). Responses to a simulated case showed that significantly fewer house officers in the EI group would intubate a patient for whom such therapy would be futile (EI = 57 per cent, LI = 87 per cent, Controls = 82 per cent). We conclude that ethics education can have an impact on house officers' confidence and their responses to a simulated case, and that the EI was more effective than the LI. Such results have implications regarding the implementation of ethics education during residency.
Clinical trials: two neglected ethical issues.
Authors: Herxheimer A
Published: November 2008

Ethical reasons are presented for requiring 1) that a proposal for a clinical trial should be accompanied by a thorough review of all previous trials that have examined the same and closely related questions, and 2) that a trial should be approved by a research ethics committee only if the investigator undertakes to register it in an appropriate register of clinical trials as soon as one exists.
Is geriatrics the answer to the problem of old age?
Authors: Millard P H
Published: November 2008

Two doctors attempt to answer this question, one a specialist in geriatric medicine, the other a psychiatrist interested in the psychiatric problems of the elderly and the old. Both, however, come to the same general conclusion: attitudes of the doctors themselves and of society must be changed. These attitudes can determine not only whether an old person lives or dies but how he lives. Old people should not have to survive in mentally suspended animation with all objectives gone but should be helped to achieve the goal of an independent life until death in their own homes.

The third paper in this miniature symposium is provided by David Hobman, of Age Concern, who amplifies the specialist views of the first two writers in his discussion of attitudes to the elderly in modern society. He hints, however, that these may shortly change as the elderly become a sophisticated and powerful lobby which governments are forced to heed.
The ethics of screening: is 'screeningitis' an incurable disease?
Authors: Shickle D , Chadwick R
Published: November 2008

Screening programmes are becoming increasingly popular since prevention is considered 'better than cure'. While earlier diagnosis may result in more effective treatment for some, there will be consequent harm for others due to anxiety, stigma, side-effects etc. A screening test cannot guarantee the detection of all 'abnormal' cases, therefore there will be false reassurance for some. A proper consideration of the potential benefit and harm arising from screening may lead to the conclusion that the programme should not be offered. A modified utilitarian approach may be used for allocation of scarce resources in health care. Ethics has an important role in this evaluation.
Clinical trials--a brave new partnership?
Authors: Thornton H
Published: November 2008

The need for informed consent is considered from the patient's viewpoint by an examination of the shortcomings of the UK Ductal Carcinoma In Situ (DCIS) trial and its failure satisfactorily to accrue both profession and patient. The impersonal, negative aspects of the informed consent process in the research situation are contrasted with the positive benefits of confidence fostered by the traditional doctor/patient relationship. The need for new research with a partnership between patient and profession, the necessity for rigorous re-assessment of treatments and care both within and outside of trials to avoid waste by the perpetration of unnecessary treatments together with the need for evaluation of the efficacy of treatments employed outside of trials, especially in 'new' conditions, to foster progress and maintain public confidence in the profession, is advocated.
Clinical trials -- a brave new partnership: a response to Mrs. Thornton.
Authors: Baum Michael
Published: November 2008

In this commentary on the previous paper it is explained that screen-detected Duct Carcinoma In Situ is effectively a new disease of unknown natural history. It is therefore impossible that 'the doctor knows best' and it is therefore both in the patient and the public's best interests that such cases are submitted to the rigours of the randomised controlled trial. Inevitably this brings the ethical dilemma of how to explain to patients the uncertainty and how to involve them in a rational decision to take part in the randomised controlled trial. It is argued that as well as there being a collective benefit for future generations of women, that we should resolve this problem now, the individual woman is likely to benefit from being treated according to a strict protocol. Nevertheless the time of diagnosis is paradoxically not the best time for a patient to become aware of these matters and it is about time that the lay public and the opinion formers recognized their responsibility to become acquainted with the benefits and the needs of the randomised controlled trial in anticipation of the day when they themselves will be patients.
Fault and the allocation of spare organs.
Authors: Smart B
Published: November 2008

This paper argues that rectificatory justice should supplement distributive justice in allocating priority of access to scarce medical resources. Where a patient is at fault for the scarcity of healthy organs a principle of restitution requires that she should give priority to the faultless. Such restitution is non-punitive, and is akin to reparation in civil law, not criminal law. However, it is doubtful whether such a principle can be fairly applied within the present culture of governmental complicity in cigarette advertising.
Paying donors and the ethics of blood supply.
Authors: Rodriguez del Pozo P
Published: November 2008

Countries may be erring in the current trend towards relying entirely on volunteers to fulfil blood and plasma needs. Complementing uncompensated blood with compensated blood is vitally necessary not only effectively to meet the blood and plasma needs of most countries, but it is also ethically sound.
Metaphysics and medical ethics: a reply.
Authors: Gillett G
Published: November 2008

The total longitudinal form view of human beings is a metaphysical view which aims to locate our moral judgements about human embryos in a broader set of attitudes and characterisations. On this basis it has explanatory power and a real function in that it grounds our ethical discussion of embryos in other discourses. Contra Leavitt, this grounding suggests a broader criterion of relevance for metaphysical discussion than asking 'what comes out of' such a discussion for a particular ethical dilemma.
Modifying autonomy--a concept grounded in nurses' experiences of moral decision-making in psychiatric practice.
Authors: Lützén K , Nordin C
Published: November 2008

Fourteen experienced psychiatric nurses participated in a pilot study aimed at describing the experiential aspect of making decisions for the patient. In-depth interviews focused on conflicts, were transcribed, coded, and categorized according to the Grounded Theory method. The theoretical construct, 'modifying autonomy' and its dimensions, such as being aware of the patient's vulnerability, caring for and caring about the patient, were identified. The findings in this study make clear the need for further research into the experiential aspect of ethical decision-making in psychiatric practice.
The ethics of allocation of scarce health care resources: a view from the centre.
Authors: Calman K C
Published: November 2008

Resource allocation is a central part of the decision-making process in any health care system. Resources have always been finite, thus the ethical issues raised are not new. The debate is now more open, and there is greater public awareness of the issues. It is increasingly recognised that it is the technology which determines resources. The ethical issues involved are often conflicting and relate to issues of individual rights and community benefits. One central feature of resource allocation is the basing of decisions on the outcomes of health care and on their subsequent economic evaluation. The knowledge base is therefore of great importance as is the audit of results of clinical treatment. Public involvement is seen as an integral part of this process. For all parts of the process, better methodologies are required.
Unproven treatment in childhood oncology--how far should paediatricians co-operate?
Authors: Jackson J
Published: November 2008

How should doctors respond to requests from parents of terminally ill children for unproven treatments to be tried? Here it is argued that doctors faced with difficult cases where (1) it is not obviously against a child's interests to undergo an unproven treatment and (2) provided the treatment does not draw extravagantly on NHS funds, it may be appropriate, though not necessarily obligatory, for doctors to comply. It is important to recognise that often there may not be 'the right response'--only alternative appropriate responses.
First trimester prenatal diagnosis: earlier is not necessarily better.
Authors: Boss J A
Published: November 2008

In the past few years considerable attention has been given to a relatively new method of prenatal diagnosis known as chorionic villus sampling (CVS). Because CVS can be performed in the first trimester it is hailed by many as a significant advance over amniocentesis. What has not been as publicized, however, are the disadvantages of CVS and earlier prenatal diagnosis. The emotional costs of CVS in terms of the greater number of both spontaneous and selective abortions following CVS, the use of CVS for sex selection and, because of the greater social acceptability of first trimester abortion, the possibility of increased pressure on women to undergo prenatal diagnosis by health insurance companies, medical professionals and government agencies, all need to be weighed against the advantages of early prenatal diagnosis.
Are withholding and withdrawing therapy always morally equivalent? A reply to Sulmasy and Sugarman.
Authors: Harris John
Published: November 2008

This paper argues that Sulmasy and Sugarman have not succeeded in showing a moral difference between withholding and withdrawing treatment. In particular, they have misunderstood historical entitlement theory, which does not automatically prefer a first occupant by just acquisition.
Research on leukaemia cells surplus to diagnostic needs in children.
Authors: Reid M M
Published: November 2008

The ability to improve diagnosis and refine prognosis in children with acute leukaemia is improving steadily. A growing number of tests can and are being performed on leukaemic cells. These include surface-marker analysis, DNA content, cytogenetics and studies of gene rearrangements. Increasingly large bone-marrow samples, now usually obtained under general anaesthesia, are required to make secure diagnoses. Ethical issues arise from three major areas. 1) Current research on leukaemia cells requested by the Medical Research Council is considered by local research ethics committees, but parents are not regularly given detailed information about or asked specifically to consent to such research; 2) substantial quantities of excess cells are stored indefinitely. This archive of stored material is a valuable resource for research but there has been little consideration of the ethical issues which arise from this practice, and 3) there is a potential for pressure to obtain increasingly large samples. 'Creeping growth' in sample size is likely to continue unless ethics committees consider future research proposals in more detail. These issues deserve attention in order that worthwhile research and its publication are not impeded for want of ethical consideration. The implications extend beyond the field of childhood leukaemia.
The teaching of medical ethics to medical students.
Authors: Glick S M
Published: November 2008

Teaching medical ethics to medical students in a pluralistic society is a challenging task. Teachers of ethics have obligations not just to teach the subject matter but to help create an academic environment in which well motivated students have reinforcement of their inherent good qualities. Emphasis should be placed on the ethical aspects of daily medical practice and not just on the dramatic dilemmas raised by modern technology. Interdisciplinary teaching should be encouraged and teaching should span the entire duration of medical studies. Attention should be paid particularly to ethical problems faced by the students themselves, preferably at the time when the problems are most on the students' minds. A high level of academic demands, including critical examination of students' progress is recommended. Finally, personal humility on the part of teachers can help set a good example for students to follow.
Patient involvement in clinical teaching.
Authors: Grant V J
Published: November 2008

This paper presents findings from a longitudinal study of patient refusals (as reported by graduating medical students) to take part in the teaching function of public hospitals. Results from a smaller study of non-patients' attitudes are also reported. Findings are discussed in terms of patients' rights, issues of personal privacy, medical education, and the public good.
Ultimate justification: Wittgenstein and medical ethics.
Authors: Hughes J
Published: November 2008

Decisions must be justified. In medical ethics various grounds are given to justify decisions, but ultimate justification seems illusory and little considered. The philosopher Wittgenstein discusses the problem of ultimate justification in the context of general philosophy. His comments, nevertheless, are pertinent to ethics. From a discussion of Wittgensteinian notions, such as 'bedrock', the idea that 'ultimate' justification is grounded in human nature as such is derived. This discussion is relevant to medical ethics in at least five ways: it shows generally what type of certainty there is in practical ethics; it seems to imply some objective foundation to our ethical judgements; it squares with our experience of making ethical decisions; it shows something of the nature of moral arguments; and, finally, it has implications for teaching medicine and ethics.
Enhancing humanistic skills: an experiential approach to learning about ethical issues in health care.
Authors: Sofaer B
Published: November 2008

An outstanding feature of the study of nursing ethics is that it raises questions concerning moral virtue, conscience, consistency and character. A considerable section of the literature is devoted to ideas of how best to teach ethics to health professionals. It has been shown that when faced with ethical dilemmas nurses tended to rely on intuition and instinct to resolve them, with little systematic analysis to help the process. Nurses who have been in practice for a number of years may experience particular difficulties in resolving ethical dilemmas, for although they may be able easily to identify ethical problems they may feel powerless to behave appropriately through lack of theoretical background and/or confidence in participating in informed debate. An educational programme was designed to meet the needs of mature registered nurses who were undertaking a post-qualification part-time honours degree in nursing studies. A variety of teaching methods were employed in teaching the nurses. These included discussion, student-led seminars, structured debate and role play. A session which dealt with sudden death and organ donation is described in some detail. Because the topic involved communication between professionals and patients and/or relatives and was linked with ethics, role play was used to explore the dynamics in these areas. The participants were invited to act out the situation as they felt it might occur. Role play highlighted the stress and shock attached to such an experience. Before working through the dynamics of a situation the nurses were conscious of being part of decision-making 'in the cold' and 'in isolation'. As a result of the experiential learning they felt more able to reflect analytically and to participate in discussions in an informed and articulate way.
Some ethical issues surrounding covert video surveillance--a response.
Authors: Southall D P , Samuels M P
Published: November 2008

In a recent article in this journal our unit was accused of a number of errors of judgment in applying covert video surveillance (CVS) to infants and children suspected of life-threatening abuse. The article implied, that on moving from the Royal Brompton Hospital in London to North Staffordshire Hospital, we failed to present our work to the Research Ethics Committee (REC). We did send our protocol to the REC though we did not consider that, after a total of 16 patients had been documented as being the subject of life-threatening abuse, this was research. The REC in Staffordshire agreed with us. We were also accused of undertaking work that should be pursued by the Police. We agree with this. However, unlike the Metropolitan Police the Staffordshire Police would not undertake CVS. We fail to agree that 'working together' with parents is necessarily practical or safe when trying to protect children from life-threatening abuse of this kind.
Teaching clinical ethics as a professional skill: bridging the gap between knowledge about ethics and its use in clinical practice.
Authors: Myser C , Kerridge I H , Mitchell K R
Published: November 2008

Ethical reasoning and decision-making may be thought of as 'professional skills', and in this sense are as relevant to efficient clinical practice as the biomedical and clinical sciences are to the diagnosis of a patient's problem. Despite this, however, undergraduate medical programmes in ethics tend to focus on the teaching of bioethical theories, concepts and/or prominent ethical issues such as IVF and euthanasia, rather than the use of such ethics knowledge (theories, principles, concepts, rules) to clinical practice. Not surprisingly, many students and clinicians experience considerable difficulty in using what they know about ethics to help them make competent ethical decisions in their day-to-day clinical practice. This paper describes the development of a seminar programme for teaching senior medical students a more systematic approach to ethical reasoning and analysis and clinical decision-making.
On withholding nutrition and hydration in the terminally ill: has palliative medicine gone too far? A reply.
Authors: Dunlop R J , Ellershaw J E , Baines M J , Sykes N , Saunders C M
Published: November 2008

Patients who are dying of cancer usually give up eating and then stop drinking. This raises ethical dilemmas about providing nutritional support and fluid replacement. The decision-making process should be based on a knowledge of the risks and benefits of giving or withholding treatments. There is no clear evidence that increased nutritional support or fluid therapy alters comfort, mental status or survival of patients who are dying. Rarely, subcutaneous fluid administration in the dying patient may be justified if the family remain distressed despite due consideration of the lack of medical benefit versus the risks. Some cancer patients who are not imminently dying become dehydrated from reversible conditions such as hypercalcaemia. This may mimic the effects of advanced cancer. These conditions should be sought and fluid replacement therapy should be given along with the specific treatments for the condition.
Double jeopardy and the use of QALYs in health care allocation.
Authors: Singer P , McKie J , Kuhse H , Richardson J
Published: November 2008

The use of the Quality Adjusted Life-Year (QALY) as a measure of the benefit obtained from health care expenditure has been attacked on the ground that it gives a lower value to preserving the lives of people with a permanent disability or illness than to preserving the lives of those who are healthy and not disabled. The reason for this is that the quality of life of those with illness or disability is ranked, on the QALY scale, below that of someone without a disability or illness. Hence we can, other things being equal, gain more QALYs by saving the lives of those without a permanent disability or illness than by saving the lives of those who are disadvantaged in these ways. But to do so puts these disadvantaged people under a kind of double jeopardy. Not only do they suffer from the disability or illness, but because of it, a low priority is given to forms of health care that can preserve their lives. This, so the objection runs, is unjust or unfair. This article assesses this objection to the use of QALYs as a basis for allocating health care resources. It seeks to determine what is sound in the double jeopardy objection, and then to show that the defender of QALYs has an adequate response to it.
Double jeopardy and the veil of ignorance--a reply.
Authors: Harris J
Published: November 2008

This paper discusses the attempt in this issue of the journal by Peter Singer, John McKie, Helga Kuhse and Jeff Richardson, to defend QALYs against the argument from double jeopardy which I first outlined in 1987. In showing how the QALY and other similar measures which combine life expectancy and quality of life and use these to justify particular allocations of health care resource, remain vulnerable to the charge of double jeopardy I am able to clarify some of the central issues concerning the value of life. In particular, the idea that the value of a life varies with its life expectancy and with its quality, understood in terms of its richness, variety, success etc, is subjected to special examination. It is shown how defenders of QALYs are committed to the view that so far from all lives being of equal value, all lives are necessarily of subtly different value. The paper then analyses the use to which the notorious 'veil of ignorance' has been put both by Singer et al and by others and shows how this device of John Rawls's cannot do the work so often assigned to it. The paper then considers the issue of hypothetical consent and the role that it can play in justifying disposing of the lives of people who have not in fact consented to their lives being disposed of in particular ways. Finally, the paper makes some points about the comprehensive nature of the data collection and storage which would be required by QALY advocates and points out the independent problems attaching to licensing such comprehensive collection and use of personal data.
Values education: a new direction for medical education.
Authors: Grundstein-Amado R
Published: November 2008

This paper suggests that medical education should redirect resources to values education, specifically developing new strategies to improve the process of clarification of values. The author suggests using the values journal method which is based on a systematic record of students' personal value systems reflected in their stories and life experience; and on their responses to case presentation. Generating a personal values journal helps students define who they are, what their social and professional roles are, what their expectations are and where they are going. Keeping values journals promotes students' decision-making capacity, and equips them with the necessary skills to teach their future patients how to generate their own value systems. The development of a well defined values journal is a preparatory stage for active participation in clinical conferences or group discussion, and for effective communal dialogue among the group's members.
'These sorts of people don't do very well': race and allocation of health care resources.
Authors: Lowe M , Kerridge I H , Mitchell K R
Published: November 2008

Recent literature has highlighted issues of racial discrimination in medicine. In order to explore the sometimes subtle influence of racial determinants in decisions about resource allocation, we present the case of a 53-year-old Australian Aboriginal woman with end-stage renal failure. The epidemiology of renal failure in the Australian Aboriginal population and amongst other indigenous peoples is discussed. We show that the use of utilitarian outcome criteria for resource allocation may embody subtle racial discrimination where consideration is not given to issues of justice, race, culture and gender. It is only where the processes by which resources are allocated are transparent, clearly defined and based upon consultation with individual patients that issues and justice are likely to be adequately addressed.
Covert video surveillance--an assessment of the Staffordshire protocol.
Authors: Thomas T
Published: November 2008

An assessment of a protocol devised to guide practitioners thinking of using covert video surveillance. Such surveillance is particularly used to help identify cases of Munchausen's syndrome by proxy. The protocol in question has been written by staff at the Academic Department of Paediatrics, North Staffordshire Hospital, Stoke-on-Trent in association with their local Area Child Protection Committee and has been commended by the Department of Health to others wishing to implement covert video surveillance.
The ethics of Soviet medical practice: behaviours and attitudes of physicians in Soviet Estonia.
Authors: Barr D A
Published: November 2008

OBJECTIVES: To study and report the attitudes and practices of physicians in a former Soviet republic regarding issues pertaining to patients' rights, physician negligence and the acceptance of gratuities from patients. DESIGN: Survey questionnaire administered to physicians in 1991 at the time of the Soviet breakup. SETTING: Estonia, formerly a Soviet republic, now an independent state. SURVEY SAMPLE: A stratified, random sample of 1,000 physicians, representing approximately 20 per cent of practicing physicians under the age of 65. RESULTS: Most physicians shared information with patients about treatment risks and alternatives, with the exception of cancer patients: only a third of physicians tell the patient when cancer is suspected. Current practice at the time of the survey left patients few options when physician negligence occurred; most physicians feel that under a reformed system physician negligence should be handled within the local facility rather than by the government. It was common practice for physicians to receive gifts, tips, or preferential access to scarce consumer goods from their patients. Responses varied somewhat by facility and physician nationality. CONCLUSION: The ethics of Soviet medical practice were different in a number of ways from generally accepted norms in Western countries. Physicians' attitudes about the need for ethical reform suggest that there will be movement in Estonia towards a system of medical ethics that more closely approximates those in the West.
Does teaching by cases mislead us about morality?
Authors: Coope C M
Published: November 2008

Those who teach or are taught medical ethics with a heavy reliance on case studies should be warned first of all that the practice tends to exaggerate the degree to which morality is controversial. Secondly, they ought to realise that it is often quite unclear what problems count as moral problems. Thirdly, they will need to bear in mind that there may be -- and presumably are -- limits to what we may regard as open to discussion. It would be quite superficial to assume that ethics teachers, going along with what is generally accepted by their colleagues in this matter, would never tempt students to disregard these limits.
Bioethics and caring.
Authors: van Hooft S
Published: November 2008

The author agrees with the critiques of moral theory offered by such writers as Bernard Williams and Alasdair MacIntyre, and uses ideas from Heidegger and Levinas to argue that caring is an ontological structure of human existence which takes two forms: caring about on self (which he calls our "self-project") and caring-about-others. This dual form of caring is expressed on four Aristotelian levels of human living which the author describes and illustrates with reference to the phenomenon of pain. It is concluded from this analysis that traditional notions of morality as imposing obligations should give way to an understanding of ethics as the social forms given to our caring for ourselves and for others. A number of implications for ethical theory are sketched out with the conclusion that virtue theory should be preferred and that the model could be worked out more fully to show that virtue theory can be internalist, particularist, pluralist, personalist and objectivist.
Betting your life: an argument against certain advance directives.
Authors: Ryan C J
Published: November 2008

In the last decade the use of advance directives or living wills has become increasingly common. This paper is concerned with those advance directives in which the user opts for withdrawal of active treatment in a future situation where he or she is incompetent to consent to conservative management but where that incompetence is potentially reversible. This type of directive assumes that the individual is able accurately to determine the type of treatment he or she would have adopted had he or she been competent in this future scenario. The paper argues that this assumption is flawed and provides theoretical and empirical evidence for this. If the assumption is false, and those taking out advance directives do not realise this, then the ethical bases for the use of these advance directives-the maximisation of the individual's autonomy and minimisation of harm-are undermined. The paper concludes that this form of advance directive should be abolished.
Exercising restraint: autonomy, welfare and elderly patients.
Authors: Dodds S
Published: November 2008

Despite moves to enhance the autonomy of clients of health care services, the use of a variety of physical restraints on the freedom of movement of frail, elderly patients continues in nursing homes. This paper confronts the use of restraints on two grounds. First, it challenges the assumption that use of restraints is necessary to protect the welfare of frail, elderly patients by drawing on a range of data indicating the limited efficacy of restraints. Secondly, it argues that the duty to respect individual autonomy extends to a duty to respect the autonomy of patients who are elderly, frail and living in nursing homes.
Potential and the early human.
Authors: Watt H
Published: November 2008

Some form of potential or "capacity" is often seen as evidence of human moral status. Opinions differ as to whether the potential of the embryo should be regarded as such evidence. In this paper, I discuss some common arguments against regarding the embryo's potential as a sign of human status, together with some less common arguments in favour of regarding the embryo's potential in this way.