bluuebunny/crossref_metadata_2025 huggingface dataset:
Should Zelen pre-randomised consent designs be used in some neonatal trials?
Authors: Allmark P
Published: November 2008

My aim is to suggest that there is a case for using a randomised consent design in some neonatal trials. As an example I use the trials of extracorporeal membrane oxygenation (ECMO) in neonates suffering pulmonary hypertension. In some trials the process of obtaining consent has the potential to harm the subject, for example, by disappointing those who end in the control group and by creating additional anxiety at times of acute illness. An example of such were the trials of extracorporeal membrane oxygenation (ECMO) in neonates suffering pulmonary hypertension. Pre-randomised consent could avoid or lessen these harms. However, a number of ethical objections are made to these research designs. They involve denial of information, using people, denial of choice, and "overselling" of allocated treatment. Furthermore, they are the wrong response; better communication might be the answer, for example. I argue that these objections are not completely persuasive. However, they are enough to suggest caution in the use of such designs.
Should childhood immunisation be compulsory?
Authors: Bradley P
Published: November 2008

Immunisation is offered to all age groups in the UK, but is mainly given to infants and school-age children. Such immunisation is not compulsory, in contrast to other countries, such as the United States. Levels of immunisation are generally very high in the UK, but the rates of immunisation vary with the public perception of the risk of side effects. This article discusses whether compulsory vaccination is acceptable by considering individual cases where parents have failed to give consent or have explicitly refused consent for their children to be immunised. In particular, the rights of: a parent to rear his/her child according to his/her own standards; the child to receive health care, and the community to be protected from vaccine-preventable infectious disease are considered. The conclusion of the article is that compulsory vaccination cannot, with very few exceptions, be justified in the UK, in view of the high levels of population immunity which currently exist.
Genetic medicine: an experiment in community-expert interaction.
Authors: Schibeci R , Barns I , Shaw R , Davison A
Published: November 2008

This project tested a two-way model of communication between lay groups and experts about genetic medicine in Perth, Western Australia. Focus group discussion with community group participants was followed by a communication workshop between community group participants and experts. Four groups of concerns or themes emerged from discussion: clinical considerations; legislative concerns; research priorities, and ethical and wider considerations. Community group concerns are not always met by the actions of "experts". This is, in part, because of the differing life-worlds of each group. However, the communication workshop showed the potential of two-way communication for both lay and expert members in understanding the others' viewpoint. Further, the approach developed here offers one possible way for community groups to participate in a substantial way in policy formulation processes.
Evaluating ethics competence in medical education.
Authors: Savulescu J , Crisp R , Fulford K W , Hope T
Published: November 2008

We critically evaluate the ways in which competence in medical ethics has been evaluated. We report the initial stage in the development of a relevant, reliable and valid instrument to evaluate core critical thinking skills in medical ethics. This instrument can be used to evaluate the impact of medical ethics education programmes and to assess whether medical students have achieved a satisfactory level of performance of core skills and knowledge in medical ethics, within and across institutions.
Managed care and ethical conflicts: anything new?
Authors: Meyers C
Published: November 2008

Does managed care represent the death knell for the ethical provision of medical care? Much of the current literature suggests as much. In this essay I argue that the types of ethical conflicts brought on by managed care are, in fact, similar to those long faced by physicians and by other professionals. Managed care presents new, but not fundamentally different, factors to be considered in medical decision making. I also suggest ways of better understanding and resolving these conflicts, in part by distinguishing among conflicts of interest, of bias and of obligation.
League tables, institutional success and professional ethics.
Authors: Cribb A
Published: November 2008

League tables are just one example of the growing importance of "institutional success" in the health service. What are the implications of attaching importance to institutional success, and what impact might this have on professional ethics? This paper considers these issues and argues that public policy processes which centre on institutional performance, and which co-opt professional loyalties to this end, shift the balance between person-centred and impersonal standpoints in health care (from the former and towards the latter). There is no attempt to make a global ethical appraisal of this putative shift but rather to raise a matter of concern for those committed to a person-centred conception of professional ethics.
The milk and the honey: ethics of artificial nutrition and hydration of the elderly on the other side of Europe.
Authors: Garanis-Papadatos T , Katsas A
Published: November 2008

Many health problems that elderly people face today relate not only to the nature of their affliction but also to the kind of treatment required. Such treatment often includes artificial nutrition and hydration, (ANH) a procedure which, despite its technical and invasive character, is still considered to be vested with symbolic meanings. It is precisely during the efforts to reach a legal consensus that the discrepancies between various cultural contexts become obvious. The following case explores the Greek clinical territory in comparison with the international situation, and the reasons why, in Greece, the right to refuse treatment is not necessarily interpreted as including the right to refuse artificial nutrition and hydration as well.
Re-examining death: against a higher brain criterion.
Authors: Fisher J
Published: November 2008

While there is increasing pressure on scarce health care resources, advances in medical science have blurred the boundary between life and death. Individuals can survive for decades without consciousness and individuals whose whole brains are dead can be supported for extended periods. One suggested response is to redefine death, justifying a higher brain criterion for death. This argument fails because it conflates two distinct notions about the demise of human beings--the one, biological and the other, ontological. Death is a biological phenomenon. This view entails the rejection of a higher brain criterion of death. Moreover, I claim that the justification of the whole brain (or brain stem) criterion of death is also cast into doubt by these advances in medical science. I proceed to argue that there is no need to redefine death in order to identify which treatments ought to be provided for the permanently and irreversibly unconscious. There are already clear treatment guidelines.
The family rule: a framework for obtaining ethical consent for medical interventions from children.
Authors: Foreman D M
Published: November 2008

Children's consent to treatment remains a contentious topic, with confusing legal precepts and advice. This paper proposes that informed consent in children should be regarded as shared between children and their families, the balance being determined by implicit, developmentally based negotiations between child and parent--a "family rule" for consent. Consistent, operationalized procedures for ethically obtaining consent can be derived from its application to both routine and contentious situations. Therefore, use of the "family Rule" concept can consistently define negligent procedure in obtaining consent from children, and could be used as a unifying framework in the development of new professional guidelines. A "guideline"-based approach to children's consent to treatment may offer greater individuality than a "rights"-based approach, though careful training and oversight will be needed for it to be effective.
Fraud, misconduct or normal science in medical research--an empirical study of demarcation.
Authors: Lynöe N , Jacobsson L , Lundgren E
Published: November 2008

OBJECTIVES: To study and describe how a group of senior researchers and a group of postgraduate students perceived the so-called "grey zone" between normal scientific practice and obvious misconduct. DESIGN: A questionnaire concerning various practices including dishonesty and obvious misconduct. The answers were obtained by means of a visual analogue scale (VAS). The central (two quarters) of the VAS were designated as a grey zone. SETTING: A Swedish medical faculty. SURVEY SAMPLE: 30 senior researchers and 30 postgraduate students. RESULTS: Twenty of the senior researchers and 25 of the postgraduate students answered the questionnaire. In five cases out of 14 the senior researchers' median was found to be clearly within the interval of the grey zone, compared with three cases for the postgraduate students. Three examples of experienced misconduct were provided. Compared with postgraduate students, established researchers do not call for more research ethical guidelines and restrictions. CONCLUSION: Although the results indicate that consensus exists regarding certain obvious types of misconduct the response pattern also indicates that there is no general consensus on several procedures.
An international survey of medical ethics curricula in Asia.
Authors: Miyasaka M , Akabayashi A , Kai I , Ohi G
Published: November 2008

SETTING: Medical ethics education has become common, and the integrated ethics curriculum has been recommended in Western countries. It should be questioned whether there is one, universal method of teaching ethics applicable worldwide to medical schools, especially those in non-Western developing countries. OBJECTIVE: To characterise the medical ethics curricula at Asian medical schools. DESIGN: Mailed survey of 206 medical schools in China, Hong Kong, Taiwan, Korea, Mongolia, Philippines, Thailand, Malaysia, Singapore, Indonesia, Sri Lanka, Australia and New Zealand. PARTICIPANTS: A total of 100 medical schools responded, a response rate of 49%, ranging from 23%-100% by country. MAIN OUTCOME MEASURES: The degree of integration of the ethics programme into the formal medical curriculum was measured by lecture time; whether compulsory or elective; whether separate courses or unit of other courses; number of courses; schedule; total length, and diversity of teachers' specialties. RESULTS: A total of 89 medical schools (89%) reported offering some courses in which ethical topics were taught. Separate medical ethics courses were mostly offered in all countries, and the structure of vertical integration was divided into four patterns. Most deans reported that physicians' obligations and patients' rights were the most important topics for their students. However, the evaluation was diverse for more concrete topics. CONCLUSION: Offering formal medical ethics education is a widespread feature of medical curricula throughout the study area. However, the kinds of programmes, especially with regard to integration into clinical teaching, were greatly diverse.
At the coalface, but on the receiving end.
Authors: Dewland P , Dewland J
Published: November 2008

In dealing with patients the doctor is very often paternalistic. No more so than when the patient is unable to help him--or herself. Modern technology allows people to be kept alive in "intensive care" where they often become an "object" at the centre of proceedings. Fortunately for them, most patients who survive intensive care cannot remember the experience though this does not mean that they were not suffering at the time. There is a strong case for explaining things as much as possible and for making practical procedures as tolerable as possible. The relatives and families of the seriously ill often have great difficulty in understanding what is happening to their loved ones and, in these situations, suffer a great deal of stress and foreboding regarding the ultimate outcome of their illness. The stress on the staff who may become "attached" to their patients often shows through as an indifferent attitude. Peter remembers three out of fourteen days in intensive care and Jane, his wife, remembers the whole experience. Here we tell our stories in the hope that they may help our medical and nursing colleagues to manage better the patients under their care in this situation.
Attitudes towards euthanasia.
Authors: Winget C , Kapp F T , Yeaworth R C
Published: November 2008

There are an infinite variety of attitudes to euthanasia, each individual response to the concept being influenced by many factors. Consequently there is a literature on the subject ranging from the popular article to papers in specialized journals. This study, however, has taken a well defined sample of people, inviting them to answer a questionnaire which was designed to elicit their attitudes to euthanasia in a way which could be analysed statistically. Nor surprisingly attitudes appeared to 'harden' as those answering the questionnaire grew more experienced in dealing with patients and also more professionally established. Thus it was found that of the seven groups questioned practising physicians showed more positive attitudes to euthanasia and their responses did not differ significantly from those of senior medical students. It is these groups which actually or potentially have to resolve the clinical dilemma posed by the dying patient.
'The implications of medical ethics'.
Authors: Goldworth A
Published: November 2008

Professor Goldworth takes up the cudgels in defence of the contemporary moral philosopher, who, he says, should indeed have a role in helping doctors to make clinical decisions based on philosophical theory; Mr. Thompson in his reply says that Professor Goldworth has misinterpreted his earlier argument. Mr. Thompson reiterates his view that the practice of medical ethics must begin with the professionals -- the doctors and nurses--although the philosopher could perhaps find himself part of a medical team. In these circumstances Professor Goldworth and Mr. Thompson would be in complete agreement. Both writers seem to be reflecting very clearly the ideas current in American and British climates of opinion.
The diagnosis of brain death
Authors: Jennett Bryan
Published: November 2008

No apologies are needed for returning to the subject of brain death and its definition. There has been so much public discussion that it is important for public confidence that the issues should be clarified. In the following two contributions - one from a professor of neurosurgery and the other from a lawyer - an attempt is made to convince doctors (if that is needed) and lay people alike that what appears to be a new bogy is not one at all but a confusion of thought arising from the use of new technology to treat brain-damaged patients. This, however, might not be the view of Mr Skegg(Journal of medical ethics, 2, 190)who, fearful of the situation, has argued for a statutory definition of death.

Professor Jennett discusses the findings of a conference of the Royal Colleges of the United Kingdom which met to try and remove uncertainty surrounding the diagnosis of brain death. In his view the Colleges' document is to be welcomed for `its authority and its practicality' and `should lead to more humane medical practice'. Mr Kennedy, from a legal position, comes to the same conclusion, that with a good code of practice, as advocated by the Royal Colleges, no legislation is called for.
Cancer and truth.
Authors: Hanganu E , Popa G
Published: November 2008

In this paper the authors discuss the continuing dilemma for doctors who have to tell a patient that he has cancer, particularly the moment when he should confirm a diagnosis that most patients have already sensed. For the writers it is most important that the doctor should be a bridge for the patient to return to his everyday world from the physical and spiritual isolation which his disease has created.
Strikes and the National Health Service: Some legal and ethical issues
Authors: Dworkin Gerald
Published: November 2008

This paper is sadly opportune. The general public is angry and bewildered if not hurt by the variety of strikes which are brought more or less forcibly to their attention. People used to understand what lay behind a strike - a demand for more pay, better conditions - but today a political element often intrudes, and it is this that worries those who ask themselves whether this or that dispute is either lawful or morally acceptable.

Professor Dworkin, a lawyer, first sets out the legal issues surrounding strikes and then advances the ethical arguments, closely relating them to the legal framework. The most interesting part of the paper, however, may well be that devoted to the moral obligation of example, in particular the example to be set by members of the medical profession and by all those caring for the sick. As public attitudes to industrial disputes `become dulled and quiescent' it is absolutely necessary that there should be a reappraisal of the moral standards of the past which coincide with a respect for the law. In the last century the term `anomie' was used to describe a `society which has shaken off its former restraints such as religion, respect for law and order and a definite moral code as to what is right and wrong'. We are living in that sort of society today, and one need not be a professional `ethicist' to recognize the signs, and hopefully, to work for the return of `ethical' values.
Focus: current issues in medical ethics.
Authors: Davis A , Horobin G
Published: November 2008

The current debates about seat belts in motor cars and the evils of smoking may only be straws in the wind if the scenario sketched in this paper were translated into a social, political programme. Then 'illness would increasingly be seen as a failure to keep healthy and thus culpable. The failures [the patients] ... must either be irresponsible and hence punishable at least by the imposition of financial penalties or insane and thus in need of corrective therapy.' If this sounds like 1984 the reader must read the whole argument set out in this paper and make his own judgment. He may not be encouraged by what he reads but he will be forewarned. There is no answer to the question, What shall I do, if this prophecy is true?
Attitudes to death: some historical notes.
Authors: Boyd K
Published: November 2008

Men have been talking of death from time immemorial - sometimes sublimely in prose and poetry, in painting and sculpture and in music - till silence seemed to fall in the recent past. Now men are again talking about death - interminably but colloquially. They talk on television, on the radio, in books and in pamphlets. Dr Kenneth Boyd therefore finds it entirely timely to offer this historical sketch of attitudes to death. The earlier part of his paper covers fairly familiar ground but his final and longest section on the work of a social historian, Philippe Ariès, may be new to many. Ariès is reinterpreting the long history of attitudes to death in a form which may well interest those who today are concerned with helping modern man to accept his own death - death which still, for most people, is the death of another, not of oneself.
Some practical results of the London Medical Group conference on iatrogenic disease.
Authors: Thorne S , Herxheimer A
Published: November 2008

Although many conferences stimulate a great deal of discussion and practical interest at the time, not so many are followed up to try and estimate what, if any, practical results followed the meeting. This the authors of this study have done. (In Britain the 'medical groups' are voluntary groupings of students at medical schools who meet to discuss ethical problems related to their profession). Sixty-five participants (not all of them students) in the conference on iatrogenic disease replied to the questionnaire, and from the answers it was clear that not only the attitudes of those responding had in some cases been changed but in some positive action had resulted, for example, in the matter of prescribing. This analysis may provide an answer to those who criticize conferences as being a waste of time and money, because much more than could be evaluated from the responses to this survey must have affected all the participants.
Artificial insemination with the husband's semen after the husband's death.
Authors: Cusine D J
Published: November 2008

Artificial insemination using the husband's semen (AIH) has always seemed more acceptable than the same procedure using donor semen. However, the layman may not even have thought of the legal problems or the moral dilemma if in fact a woman is inseminated using her husband's frozen semen after his death. In the USA there are already sperm banks set up by private individuals, generally for the use of those marriage partners when the husband has had a vasectomy and afterwards a child is desired. If such private sperm banks were set up in Britain complex legal problems would follow, quite apart from the moral issue as to whether it was desirable to bring a child into the world deliberately having deprived him of a father from the start. These are the issues which Mr Cusine thinks should be carefully considered before doctors, lawyers and the women potentially concerned are confronted with a new dilemma.
Gifts, exchanges and the political economy of health care. Part I: should blood be bought and sold?
Authors: Plant R
Published: November 2008

Should blood be bought and sold is in crude terms the question asked and answered by Richard Titmuss in his recent book The Gift Relationship. Dr Raymond Plant, a lecturer in philosophy at Manchester University, analyses Titmuss' arguments in a paper which we are printing in two parts. Titmuss has taken the provision of blood as his example of the gift relationship--and by extension that of health care generally. Dr Plant considers in turn each of Titmuss' arguments that blood should not be a marketable commodity, the moral objections to which seem to be the erosion of freedom and of truth telling, the separation of society through the cash nexus, and its converse that the provision of health care is a means for the integration of society. Dr Plant also examines the views of other commentators on the Titmuss' theory of the value of a 'free' blood transfusion service and other medical care as a means of integration in society, and ends with his promise that in the second part of his paper he will examine Titmuss' principles not in terms of the market but rather as related to the principle of social justice.
Medical migration and world health
Authors: Fraser Alan G
Published: November 2008

Everyone knows that British doctors are emigrating and that other doctors, mostly from the third world, are immigrating to Britain. Also everyone thinks that he knows the reasons why. However, the Edinburgh Medical Group thought the various reasons for this medical migration should be examined more closely, and held a symposium (Chairman, Professor A S Duncan, Professor Emeritus of Medical Education in the University of Edinburgh) to examine the causes for medical migration at the present time.

Medical teaching and practice is still basically as it has been developed in the West and so overseas doctors trained in Britain take with them not only the medical knowledge and skills but also the attitudes of the West when they return to their own countries. Consequently they wish to settle in the towns and practise as consultants when the real medical problems in many of the developing countries are those of a rural population needing health care rather than treatment in what have been called `disease palaces'. As speakers made clear, a new responsibility must fall on those training doctors from overseas in the British medical schools to fit them not for the dream world of the sophisticated medical scene but for the realities of working in often badly equipped clinics and dealing with common conditions such as malnutrition and other problems of maternity and child health.

The symposium also included discussions as to why British doctors wished to emigrate. Money seemed to be the most compelling motive, but opportunities were being limited for their migration for economic and political reasons.

Finally, a look at the whole of the medical scene in Britain: perhaps the standard sought in Britain both by the doctor and the patient is too high and too individualistic. Events will show if this be true.
Sterilisation: the Aberdeen experience, and some broader implications.
Authors: Teper S
Published: November 2008

In her paper, Sue Teper outlines the various methods of contraception or fertility control and their relationship to sterilisation. She also considers a particular group of women in Aberdeen as a mini case-study. From these two aspects of sterilization develops a third--that of broader medical and economic issues. Sterilisation usually concerns patients who are free from illness, therefore the attitudes of medical personnel are much more relevant to whether or not the operation is performed on request purely as a means of fertility control, rather than for medical reasons where the patient may be at risk were a pregnancy to occur. Ms Teper calls for medical staff in this instance to clarify their own attitudes in decisions which involve surgical skills and healthy patients.
Fetal survival--who decides?
Authors: McFadyen I R
Published: November 2008

In this paper Iain McFadyen highlights a modern ethical dilemma. In each case the fetus was recognised to be in danger, but in both cases the advice given in the fetal interest was refused by the mothers. Both the mother and the physician were concerned for the fetus, but their differing actions and reasons pose the dilemma--who decides?
Leukaemia in children of Jehovah's Witnesses: issues and priorities in a conflict of care.
Authors: Kearney P J
Published: November 2008

Throughout this paper PJ Kearney attempts to balance the risks and benefits of different approaches in paediatric oncology. Decisions have to be considered both in the short and the long term. Where religious beliefs, such as those held by Jehovah's Witnesses in relation to blood transfusions, conflict with normal medical practice the decision is often removed from the doctor, parents or patient to the courts. This sort of solution can be counter-productive, especially as good health care and subsequent recovery rely, to a large extent, on good relationships between and among the parties concerned. Destruction of these relationships, for whatever reason, often has a detrimental effect on the patient, in whose best interest everyone believes they are acting.
The teaching of medical ethics: University College, Cork, Ireland.
Authors: Clarke D D
Published: November 2008

Dolores Dooley Clarke describes how the course in medical ethics at University College, Cork is structured, how it has changed and how it is likely to change as time goes on. Originally, the students seemed to view it as an intrusion 'to be tolerated' in their programme of 'strictly medical' studies. However, having moved on from that and away from the lecturer always being a Roman Catholic priest as well as a member of the Philosophy Department, the students now appear to view it as producing a stimulus for a new interest in the area of ethics for physicians. This seems to have come about through the more extensive participation of students in researching and presenting issues of medical ethics.
Political neutrality and international cooperation in medicine.
Authors: Merskey H
Published: November 2008

International cooperation is an integral part of furthering medical and scientific progress. Many specilist societies exist for that purpose and have written into their constitutions that such cooperation and coordination is their aim. They hope to achieve their aims by exchange, in all languages, of information and by so doing strengthen the relations between individual physicians and scentists as well as between corporate professional bodies from different countries. However, at the same time emphasis is laid on the political neutrality of such organsations. Increasingly, this 'neutrality' is being questioned as doctors and scientists become aware of abuse and distortion of their profession taking place in other countries. H Merskey highlights the problems and offers his opinion on the ethics of maintaining these professional relationships with colleagues abroad who are involved in such abuse and distortion.
Pain in childbirth.
Authors: Kitzinger S
Published: November 2008

Sheila Kitzinger describes pain and its control throughout the various stages of childbirth. She stresses the value of antenatal preparation as well as the need for a supportive environment during the labour stages. All concerned--the porspective parents, doctors, midwives and any other personnel in a maternity unit should be educated to be able to provide such an environment.
Human rights and distributive justice in health care delivery.
Authors: Shelton R L
Published: November 2008

This paper was first presented at the Annual Meeting of the American Society of Christian Ethics, Toronto School of Theology, Toronto, Ontario in January 1977. Robert Shelton aims to focus on the concept of 'right to health care,' its related principle, 'distributive justice' in an attempt to suggest 'where we are' at present and where we perhaps ought to be heading. The paper is divided into three parts, which in their turn explore the moral grounds, the US general public's policy and the part justice and government are likely to play in the development and distribution of health care. He concludes by highlighting 'omissions', an intentional one of his own and the other a major gap in the literature.
Patients, doctors and experimentation: doubts about the Declaration of Helsinki.
Authors: Belsey A
Published: November 2008

The World Medical Association's Declaration of Helsinki offers guidelines to doctors engaged in biomedical research with human subjects. The fundamental distinction of the Declaration is between clinical research combined with professional care and non-clinical scientific research. If hospital patients are the experimental subjects, then the former research must be carried out by the patient's own doctor, whereas the latter research must not be; it must be carried out by other doctors. The relevance of the distinction between the patient's own doctor and other doctors is challenged and an alternative conception of the patient-doctor relationship is drawn, together with an alternative justification, based on the work of Hans Jonas, of the use of patients in research. Finally, the political nature of the patient-doctor relationship is mentioned, and it is claimed that the alternative conception of this relationship developed in the paper is more in line with the ethical principles of the Hippocratic tradition.
Dying while living: a critique of allowing-to-die legislation.
Authors: Lappé M
Published: November 2008

Several US states are enacting 'right-to-die' laws, in the wake of the Karen Quinlan case. But the way such a law is drafted may cast doubt on a patient's existing common law right to control all aspects of his own treatment; it may give legal sanction to a lower standard of medical care that society at present expects from doctors; and it may lead to conflict between the patient's directive and his doctor's clinical judgement which cannot readily be resolved. The laws themselves are categorised as a) legalising active killing or b) defining rights of patients to control treatment or c) assigning to others the rights to control treatment where the patient is not competent. The California law is discussed critically. The conclusion is that such legislation is not a satisfactory answer to the ethical problem of euthanasia.
Paradoxical traps in therapeutics: some dilemmas in medical ethics.
Authors: Lowental U
Published: November 2008

The doctor-patient relationship is examined an emphasis on the comparison between professional and moral principles. Many therapeutic measures have opposite-directed alternative steps with an equal degree of justification, so that no logical preference is attainable and conflicts ensue. Thus patients come for relief and are ordered to endure further pain and discomfort; or weaker individuals exaggerate their complaints hypochomdriacally, and thus need a great deal of understanding, yet paradoxically they are prone to receive less support than stronger ones. Further conflicts arise between our devotion to human well-being and dignity, and our obligation to disrespect some of their rights for self-determination. Furthermore, various dutifully performed doctoring activities run counter to our own social needs and interests; last, but not least, human imperfection colours some of our decisions, putting a definite blemish on their value. In conclusion, physicians must bear the constant burden of paradoxically-opposed alternatives, and they confront pitfalls of worongdoing at every therapeutic step. Their only guidelines are intuition and professional dedication.
What is medicine?: towards a philosophical approach.
Authors: Greaves D
Published: November 2008

The failure of Western medicine to deal with many of the problems it is currently facing has led to an awareness of the need for a fundamental reappraisal. The way in which medical concepts derived from the nineteenth century have brought technical medical advances in this century and the alliances that medicine has made with statistics and more recently the social sciences, have prevented a questioning of medicine's underlying assumptions. Thus, despite a number of critical initiatives from both within and outside medicine, there has been no coherent development to seriously confront the question 'what is medicine?'. It is suggested that the basis for such a development depends on the return to a philosophical questioning of our conceptual understanding of disease, a subject which has largely been ignored during the past hundred years.
Help yourself to good health?
Authors: Myer E M
Published: November 2008

In recent years more support has been given to the idea of Health Education and there are strong reasons for believing that such schemes of prevention may receive much more financial backing from governments. It is being realised, also, that many of our 'ills' may be attributed to an over-reliance on medical technology. There is reason to believe that in years to come the emphasis will be placed on the fostering of mental health in programmes of Health Education enabling the individual to take a responsible attitude in learning how to seek out health hazards for himself without over-reliance on others.
Law and medical ethics.
Authors: Frenkel D A
Published: November 2008

Summarising the interrelationship between law and medical ethics, I would say that in cases which do not touch the patient's body or integrity, such as professional secrecy, statutory law may take precedence over rules of medical ethics. But in cases where the human subject becomes a victim because of domestic statutory laws which are in contradiction with medical ethics, the medical practitioners should insist on adhering to their professional standards in such a way that the legislators will have to adapt their legislations to the laws of humanity and public conscience. Legislators, as well as medical practitioners, should not forget that the term 'being' is preceded and qualified by 'human'.
The nature of confidentiality.
Authors: Thompson I E
Published: November 2008

This paper examines confidentiality and its nature and analyses the guidelines laid down by the Hippocratic Oath as well as the British and World Medical Associations for maintaining such confidentiality between doctor and patient. There are exceptions to practically any code of rules and this is true also for confidentiality. Some of these exceptions make it appear that very little is confidential. The three values implicit in confidentiality would seem to be privacy, confidence and secrecy. Each of these values is discussed and developed in this paper. In conclusion, the question is suggested that maybe in the face of death, doctor and patient need to re-examine the pre-suppositions of privacy, confidence and secrecy on which the confidential relationship is based.
Learning about death.
Authors: MacLean U
Published: November 2008

This paper outlines briefly some of the research which has been carried out on attitudes to terminal illness and its care. The writer feels that not enough effort is being put into the teaching of this subject in our medical schools and Universities, and that doctors themselves are the ones who often wish to 'duck' the issue of dealing with disability and the dying. However, with the increasing awareness, through both the research and the growing allied literature, the writer feels that there is no longer any excuse for omitting this subject from the curricula for doctors and nurses in training.
Choosing priorities.
Authors: Gray J A
Published: November 2008

Dr Gray leaves us with a question at the conclusion of his article--how should we choose priorities? He says that the debate so far has been mainly on what we should choose, but perhaps we should consider how to choose even more. Under the various subheadings of Criteria, Principles and Persons Dr Gray sets out the pros and cons of the arguments in the priority debates and tries to offer some more specific guidelines to offset the criticism that the government's priority discussions have been too generalised. Yet this is a difficult task when everyone's priorities are so different.
The general practitioner and the problems of battered women.
Authors: Pahl J
Published: November 2008

This paper discusses the responsibility of general practitioners who are consulted by women who have been physically injured by the men with whom they live. The paper draws on a study of 50 women who were interviewed at a refuge for battered women, and considers the help which they received, or did not receive, from their general practitioners. Such women are likely to face many difficulties: it is perhaps the essence of their problem that, because it is potentially the concern of so many people, it can so easily become the concern of nobody--except of the woman herself.
Self-ownership, abortion and infanticide.
Authors: Paul E F , Paul J
Published: November 2008

Doctors have been placed in an anomalous position by abortion laws which sanction the termination of a fetus while in a woman's womb, yet call it murder when a physician attempts to end the life of a fetus which has somehow survived such a procedure. This predicament, the doctors' dilemma, can be resolved by adopting a strategy which posits the right to ownership of one's own body for human beings. Such an approach will generate a consistent policy prescription, one that sanctions the right of all pregnant women to abortions, yet grants the fetus, after it becomes viable as a potentially independent person, a right to its own body. The doctors' dilemma is surmounted, then, by requiring that abortions of viable fetuses be performed in a manner that will produce a live delivery. Hence, infanticide and termination of viable fetuses are proscribed.
Killing, letting die and euthanasia.
Authors: Husak D N
Published: November 2008

Medical ethicists debate whether or not the moral assessment of cases of euthanasia should depend on whether the patient is 'killed' or 'allowed to die'. The usual presupposition is that a clear distinction between killing and letting die can be drawn so that this substantive question is not begged. I contend that the categorisation of cases of instances of killing rather than as instances of letting die depends in part on a prior moral assessment of the case. Hence is it trivially rather than substantively true that the distinction has moral significance. But even if a morally neutral (ie non-question begging) distinction could be drawn, its application to the euthanasia controversy is problematic. I illustrate the difficulties of employing this distinction to reach moral conclusions by critically discussing Philippa Foot's recent treatment of euthanasia. I conclude that even if an act of euthanasia is an instance of killing, and there exists a prima facie moral duty not to kill, and no more stringent duty overrides this duty, one still cannot determine such an act to be morally impermissible.
Self-help in health care
Authors: Robinson David
Published: November 2008

This paper was given at a London Medical Group symposium held at Middlesex Hospital Medical School in May 1979, on `Self-help groups - England's barefoot doctors'.

Dr Robinson gives a brief history of some of the reasons why self-help groups have evolved and how they work. He also looks at how the `professionals' can and do relate to them.
The Marquis de Sade and induced abortion.
Authors: Farr A D
Published: November 2008

In 1795 the Marquis de Sade published his La Philosophic dans le boudoir, in which he proposed the use of induced abortion for social reasons and as a means of population control. It is from this time that medical and social acceptance of abortion can be dated, although previously the subject had not been discussed in public in modern times. It is suggested that it was largely due to de Sade's writing that induced abortion received the impetus which resulted in its subsequent spread in western society.
The transsexual dilemma: being a transsexual.
Authors: Mason N
Published: November 2008

With few exceptions, a solution to any problem will bring new difficulties. These may or may not be worse than the original problem, and one must decide, not between problem and answer, but between degrees of difficulty. Is the new situation really going to be better than the last? This is undoubtedly the situation with the transsexual. It is undeniable that in the majority of cases the treated transsexual is an infinitely happier person than the one who has not undergone therapy, but as a result of this treatment there arises a host of new difficulties. Using personal experience, it is my intention to illustrate the problems which beset the transsexual before, during and after treatment. It will then be possible to ascertain whether or not, in spite of these difficulties, there is in fact a dilemma. Is there indeed any choice?
Transsexualism: a medical perspective.
Authors: Armstrong C N
Published: November 2008

Transsexualism, a condition in which from earliest recollection the individual is unshakeably convinced he or she has been endowed with the wrong physical sexual body presents one of the most difficult problems as regards management and treatment in clinical medicine. The aetiology and treatment is discussed and the problems with which the medical practitioner may be faced in advising his transsexual patient which include change in social role and marriage and the difference between sex and gender.
Doctors and torture: the police surgeon.
Authors: Burges S H
Published: November 2008

Much has been written by many distinguished persons about the philosophical, religious and ethical considerations of doctors and their involvement with torture. What follows will not have the erudition or authority of the likes of St Augustine, Mahatma Gandi, Schopenhauer or Thomas Paine. It represents the views of a very ordinary person; a presumption defended by the submission that many very ordinary persons have been, and will be, instruments for effecting, assisting or condoning the physical or mental anguish of others. As practitioners of medicine, we are particularly vulnerable, since our particular knowledge and our privileged position may be so easily abused--to the detriment of others. Those of us who practice clinical forensic medicine have even greater responsibility by virtue of our daily contact with the enforcement of law, criminal procedure, and the machinations of the judiciary. We are thus particularly well placed to monitor, encourage or discourage the occurrence of evil practices within the community. It is imperative, therefore, that the ordinary doctor should be cognisant of, and be party to, a code of conduct formulated by his peers and having reference to his obligations as a citizen, and doctor, and to his ability to manipulate human activity. Forensic physicians have further discretionary powers as arbiters in the marriage of the art and ethics of healing with the principles and practice of justice.
Triage and the patient with renal failure.
Authors: Parsons V , Lock P
Published: November 2008

The call for 'triage' as a specific policy for the selection of patients presenting with chronic renal failure, in the light of increasingly limited resources prompted us to question nephrologist on their bases for selection. We discovered no absolute criteria for rejection, but a consensus of opinion against those with additional and complicating factors to their renal disease such as age, hepatitis carriers and mental illness-a bias seen throughout the National Health Service. In this paper we discuss the validity of such criteria, the implications of the currently pragmatic and often covert practice of selection, and in this potentially finite area of demand we question the rationale for the limitation of resources.
The concept of 'competence' in medical ethics.
Authors: Baumgarten E
Published: November 2008

Dr Baumgarten analyses three possible justifications for doctors to decide that a patient is 'incompetent' to make or participate in medical decisions affecting him, and points out the difficulties of each. He argues that the degree to which a patient relinquishes control over decision-making which affects him will vary in different circumstances and should be explicitly agreed in the initial doctor-patient contract, rather as it often is when a client employs a professional to invest money on his behalf.
A philosophy of a clinically based medical ethics.
Authors: Thomasma D C
Published: November 2008

Pellegrino and Siegler have argued that medical ethics must be taught 'at the bedside', or clinically. This paper is an attempt to establish the need for clinical teaching of medical ethics both to medical students and to medical ethicists who are not physicians. Through a critique of six positions regarding the aims of medical ethics, four principles are established which are the basis of a philosophy of education for medical ethics. The need for a clinically-based educational programme in medical ethics is thereby established, not on practical grounds, but on solid philosophical ones. The paper concludes with practical examples of a clinically-based medical ethics programme following from the four principles.
Even dying must be edited: further thoughts on Joan Robinson.
Authors: Curry S , Zucker A , Trautmann J
Published: November 2008

"Joan Robinson: One Woman's Story' is a cinéma vérité style record of a woman's losing struggle against ovarian cancer. The film has been shown now twice on the American Public Television Network. It has received good notices primarily from the lay press. Yet the film depicts much that is out-of-date and much that is debatable. In general, we feel that it presents a depressing picture of the cancer patient. This was not Joan Robinson's intention and her bravery only serves to highlight this picture of suffering with cancer. We point to specific flaws in the film. We then go on to account for why many reviewers seem to have been blind to these flaws. It is suggested that criteria for good works of art, for good public health information, and for admirable personal traits were confused.