bluuebunny/crossref_metadata_2025 huggingface dataset:
Experienced consent in geriatrics research: a new method to optimize the capacity to consent in frail elderly subjects.
Authors: Rikkert M G , van den Bercken J H , ten Have H A , Hoefnagels W H
Published: November 2008

OBJECTIVES: Cognitive and sensory difficulties frequently jeopardize informed consent of frail elderly patients This study is the first to test whether preliminary research experience could enhance geriatric patients' capacity to consent. DESIGN/SETTING: A step-wise consent procedure was introduced in a study on fluid balance in geriatric patients. Eligible patients providing verbal consent participated in a try-out of a week, during which bioelectrical impedance and weight measurements were performed daily. Afterwards, written informed consent was requested. Comprehension, risk and inconvenience scores (ranges: 0-10) were obtained before and after the try-out by asking ten questions about the study's essentials and by asking for a risk and inconvenience assessment on a ten-points rating scale. SUBJECTS AND RESULTS: Seventy of the 78 eligible subjects started the try-out and 53 (68%) provided written consent. The comprehension score increased from 5.0 (+/- 2.3) to 7.0 (+/- 1.9) following the try-out (P < 0.001). The number of subjects capable of weighing risks and inconveniences increased from 32 to 48 (P < 0.001). CONCLUSIONS: Research experience improved the capacity to consent, still enabling an acceptable participation rate. Therefore, experienced consent seems a promising tool to optimize informed consent in frail elderly subjects.
Medical negligence and wrongful birth actions: Australian developments.
Authors: Petersen K
Published: November 2008

Wrongful birth actions aim to compensate litigants who are negligently deprived by health professionals of their right to reproductive choice. Access to safe and legal abortion is integral to the action and wrongful birth claims in the United Kingdom have been facilitated by the Abortion Act 1967 (as amended). The recent Australian case CES v Superclinics (1995) 38 NSWLR 47 shows how judicial confusion about the legality of abortion can result in judges condoning medical negligence. The Superclinics case also suggests that doctors are not required to provide pregnant women with the same standard of care as other patients. These developments show that law can become incoherent and health professionals can act negligently with impunity when reproductive choice does not have a secure legal foundation.
Medical decisions concerning the end of life: a discussion with Japanese physicians.
Authors: Asai A , Fukuhara S , Inoshita O , Miura Y , Tanabe N , Kurokawa K
Published: November 2008

OBJECTIVES: Life-sustaining treatment at the end of life gives rise to many ethical problems in Japan. Recent surveys of Japanese physicians suggested that they tend to treat terminally ill patients aggressively. We studied why Japanese physicians were reluctant to withhold or withdraw life-support from terminally ill patients and what affected their decisions. DESIGN AND PARTICIPANTS: A qualitative study design was employed, using a focus group interview with seven physicians, to gain an in-depth understanding of attitudes and rationales in Japan regarding medical care at the end of life. RESULTS: Analysis revealed that physicians and patients' family members usually make decisions about life-sustaining treatment, while the patients' wishes are unavailable or not taken into account. Both physicians and family members tend to consider withholding or withdrawing life-sustaining treatment as abandonment or even killing. The strongest reason to start cardiopulmonary resuscitation- and to continue it until patients' family members arrive-seems to be the family members' desire to be at the bedside at the time of death. All physicians participating in our study regarded advance directives that provide information as to patients' wishes about life-sustaining treatment desirable. All expressed concern, however, that it would be difficult to forego or discontinue life-support based on a patient's advance directive, particularly when the patient's family opposed the directive. CONCLUSION: Our group interview suggested several possible barriers to death with dignity and the appropriate use of advance directives in Japan. Further qualitative and quantitative research in this regard is needed.
Local Research Ethics Committees can audit ethical standards in research.
Authors: Berry J
Published: November 2008

OBJECTIVES: To show that a Local Research Ethics Committee (LREC) can carry out an audit of ethical standards in research. To find out if a researcher met certain ethical standards in recruiting subjects for clinical trials and in obtaining their consent. DESIGN: Postal questionnaire. SETTING: Clinical research by one doctor during one year. SUBJECTS: Eleven patients entered in clinical trials. MAIN OUTCOME MEASURES: Success in ethics committee obtaining data. Achievement of ethical standards in recruitment of subjects and in obtaining consent. RESULTS: The audit was successfully carried out and standards were partly met. CONCLUSIONS: Local Research Ethics Committees can carry out audits of the conduct of research projects which they have approved. Provision for possible audits can be made at the time of application to the committee. Our committee thought the ethical standards in the research which we audited were acceptable.
Questionable ethics--whistle-blowing or tale-telling?
Authors: Chambers T
Published: November 2008

Renal biopsy is a potentially hazardous procedure, generally performed for therapeutic reasons. An open renal biopsy was performed when there appeared to be no accepted clinical indication and its results published in a specialty journal, whose editors declined publication of subsequent correspondence, questioning the ethical propriety of such a procedure. The implications for clinical practice, authors, editors and readers are discussed.
Postmodernity and a hypertensive patient: rescuing value from nihilism.
Authors: Smith S
Published: November 2008

Much of postmodern philosophy questions the assumptions of Modernity, that period in the history of the Western world since the Enlightment. These assumptions are that truth is discoverable through human reason; that certain knowledge is possible; and furthermore, that such knowledge will provide a basis for the ineluctable progress of Mankind. The Enlightenment project is underwritten by the conviction that knowledge gained through the scientific method is secure. In so far as biomedicine inherits these assumptions it becomes fair game for postmodern deconstruction. Today, perhaps more than ever, plural values compete, and contradictory approaches to health, for instance, garner support and acquire supremacy through consumer choice and media manipulation rather than evidence-based science. Many doctors feel a tension between meeting the needs of the patient face to face, and working towards the broader health needs of the public at large. But if the very foundations of medical science are questioned, by patients, or by doctors themselves, wherein lies the value of their work? This paper examines the issues that the anti-foundationalist thrust of postmodernism raises, in the light of a case of mild hypertension. The strict application of medical protocol, derived from a nomothetic, statistical perspective, seems unlikely to furnish value in the treatment of an individual. The anything goes, consumerist approach, however, fares no better. The author argues that whilst value cannot depend on any rationally predetermined parameters, it can be rescued, and emerges from the process of the meeting with the patient.
Autonomy in the face of a devastating diagnosis.
Authors: Spriggs M
Published: November 2008

Literary accounts of traumatic events can be more informative and insightful than personal testimonials. In particular, reference to works of literature can give us a more vivid sense of what it is like to receive a devastating diagnosis. In turn this can lead us to question some common assumptions about the nature of autonomy, particularly for patients in these circumstances. The literature of concentration camp and labour camp experiences can help us understand what it is like to have one's life-plans altered utterly and unexpectedly. Contrary to common views of autonomy which have difficulty in characterising autonomous action when long-standing assumptions are suddenly lost, these examples show that autonomy is possible in these circumstances. We need a theory of autonomy which can deal with traumatic events and is useful in the clinical context.
Applying best interests to persistent vegetative state--a principled distortion?
Authors: Fenwick A J
Published: November 2008

"Best interests" is widely accepted as the appropriate foundation principle for medico-legal decisions concerning treatment withdrawal from patients in persistent vegetative state (PVS). Its application appears to progress logically from earlier use regarding legally incompetent patients. This author argues, however, that such confidence in the relevance of the principle of best interests to PVS is misplaced, and that current construction in this context is questionable on four specific grounds. Furthermore, it is argued that the resulting legal inconsistency is distorting both the principle itself and, more particularly, individual patient interests.
Reaching targets in the national cervical screening programme: are current practices unethical?
Authors: Foster P , Anderson C M
Published: November 2008

The principle of informed consent is now well established within the National Health Service (NHS) in relation to any type of medical treatment. However, this ethical principle appears to be far less well established in relation to medical screening programmes such as Britain's national cervical screening programme. This article will critically examine the case for health care providers vigorously pursuing women to accept an invitation to be screened. It will discuss the type of information which women would need in order to make an informed decision about whether or not to be screened. The lack of such information in current patient leaflets on the "smear test" will then be documented. Finally, the article will explore possible ways of maximising women's autonomy in relation to the cervical screening programme without sacrificing any of its main benefits.
The subtle politics of organ donation: a proposal.
Authors: Eaton S
Published: November 2008

Organs available for transplantation are scarce and valuable medical resources and decisions about who is to receive them should not be made more difficult by complicated calculations of desert. Consideration of likely clinical outcome must always take priority when allocating such a precious resource otherwise there is a danger of wasting that resource. However, desert may be a relevant concern in decision-making where the clinical risk is identical between two or more potential recipients of organs. Unlikely as this scenario is, such a decision procedure makes clear the interdependence of organ recipient and organ donor and hints at potential disadvantages for those who are willing to accept but unwilling to donate organs (free-riders). A combined opting-out and preference system weakens many of the objections to opting-out systems and may make the decision to donate organs on behalf of their deceased relatives easier for families.
Balancing the quality of consent.
Authors: Hansson M O
Published: November 2008

The rule that one must obtain informed consent is well established in medical ethics and an intrinsic part of clinical practice and of research in biomedicine. However, there is a tendency that the rule today is being applied too rigidly and with too little sensitivity to the values that are at stake in connection with different kinds of research protocols. It is here argued that the quality of consent needs to be balanced against variables such as degree of confidentiality and importance of values at stake, in order to be ethically acceptable. Appropriate information and consent procedures should be adjusted accordingly. Three levels are suggested, ranging from extensively informed consent with both written and oral information, through informed refusal with only a limited amount of information given to, at the other end of the scale, just making relevant information available.
Limits of neonatal treatment: a survey of attitudes in the Danish population.
Authors: Norup M
Published: November 2008

OBJECTIVES: To study attitudes in the Danish population towards treatment of severely handicapped and extremely preterm infants and to define areas of consensus and controversy. DESIGN: Mail-delivered questionnaire. SETTING: Denmark. Survey sample--A random sample of 1080 persons aged from 18 to 45 years. RESULTS: The overall response rate was 68%. There was strong consensus (more than 75% agreement) that life-prolonging treatment should be provided for an infant born after 24 weeks' gestation with respiratory distress and, for an infant with myelomeningocele, when the parents were in favour of treatment. Further, there was almost uniform agreement that not all infants should be treated no matter how serious the condition. Major controversies concerned the severity of a condition needed to justify omission of life-prolonging treatment, the role of parental attitude and the options in non-treatment cases. Forty-six per cent thought it ought to be legal to kill the infant in at least some of these cases. CONCLUSION: Although the study revealed wide divergences of opinion with regard to questions about limits of treatment and about end-of-life decisions it also showed that there was general acceptance both that life-prolonging treatment ought to be provided even in relatively severe cases if this was in accordance with parental wishes, and that life should not be saved at all costs.
The problematic symmetry between brain birth and brain death.
Authors: Jones D G
Published: November 2008

The possible symmetry between the concepts of brain death and brain birth (life) is explored. Since the symmetry argument has tended to overlook the most appropriate definition of brain death, the fundamental concepts of whole brain death and higher brain death are assessed. In this way, a context is provided for a discussion of brain birth. Different writers have placed brain birth at numerous points: 25-40 days, eight weeks, 22-24 weeks, and 32-36 weeks gestation. For others, the concept itself is open to question. Apart from this, it needs to be asked whether a unitary concept is an oversimplification. The merits of defining two stages of brain birth, to parallel the two definitions of brain death, are discussed. An attempt is then made to map these various stages of brain birth and brain death onto a developmental continuum. Although the results hold biological interest, their ethical significance is less evident. Development and degeneration are not interchangeable, and definitions of death apply specifically to those who are dying, not those who are developing. I conclude that while a dual concept of brain death has proved helpful, a dual concept of brain birth still has problems, and the underlying concept of brain birth itself continues to be elusive.
The unpaid donation of blood and altruism: a comment on Keown.
Authors: McLachlan H V
Published: November 2008

In line with article 3.4 of EC directive 89/381, Keown has presented an ethical case in support of the policy of voluntary, unpaid donation of blood. Although no doubt is cast on the desirability of the policy, that part of Keown's argument which pertains to the suggested laudability of altruism and of its encouragment by social policy is examined and shown to be dubious.
Teaching medical students on the ethical dimensions of human rights: meeting the challenge in South Africa.
Authors: London L , McCarthy G
Published: November 2008

SETTING: Previous health policies in South Africa neglected the teaching of ethics and human rights to health professionals. In April 1995, a pilot course was run at the University of Cape Town in which the ethical dimensions of human rights issues in South Africa were explored. OBJECTIVES: To compare knowledge and attitudes of participating students with a group of control students. DESIGN: Retrospective cohort study. SUBJECTS: Seventeen fourth-year medical students who participated in the course and 13 control students from the same class, matched for gender. INTERVENTIONS: Students participated in a one-week module on ethics and human rights. Five months after the course had been run, students completed a semi-structured questionnaire exploring their knowledge and attitudes with regards to ethics and human rights issues. MAIN OUTCOME MEASURES: Knowledge scores, attitude scores and various individual indicators of attitude. RESULTS: Clear benefits for overall knowledge score, for four out of five individual knowledge questions and for one of the attitude questions, were demonstrated. Participating students also appeared to be more convinced of the need for teaching on the ethical dimensions of human rights at postgraduate level and that such teaching should also be integrated in the curriculum. The low response rate amongst controls may have selected students who were more socially conscious, thereby leading to an underestimate of the true impact of the course. CONCLUSION: The evaluation indicates clear benefits of the course for undergraduate students, and supports arguments for the inclusion of such courses in the training of health professionals. This is particularly important given the challenges posed by the Truth and Reconciliation Commission to the health professions to address past complicity in human rights abuses through reorientation of medical training in South Africa.
Tensions in setting health care priorities for South Africa's children.
Authors: Landman W A , Henley L D
Published: November 2008

The new South African constitution commits the government to guarantee "basic health services" for every child under 18. Primary health care for pregnant women and children under six and elements of essential primary health care have received priority. At present, there is little analysis of the moral considerations involved in making choices about more advanced or costly health care which may, arguably, also be "basic". This paper illustrates some of the tensions in setting priorities for a just macro-allocation of children's health care, given the realities of need and scarce resources, and the commitment to equality of basic opportunities.
Ethics and aims in psychotherapy: a contribution from Kant.
Authors: Callender J S
Published: November 2008

Psychotherapy is an activity which takes many forms and which has many aims. The present paper argues that it can be viewed as a form of moral suasion. Kant's concepts of free will and ethics are described and these are then applied to the processes and outcome of psychotherapy. It is argued that his ideas, by linking rationality, free will and ethics into a single philosophical system, offer a valuable theoretical framework for thinking about aims and ethical issues in psychotherapy.
The use of patients in health care education: the need for ethical justification.
Authors: Bindless L
Published: November 2008

This paper addresses ethical concerns emanating from the practice of using patients for health care education. It shows how some of the ways that patients are used in educational strategies to bridge theory-practice gaps can cause harm to patients and patient-practitioner relationships, thus failing to meet acceptable standards of professional practice. This will continue unless there is increased awareness of the need for protection of human rights in teaching situations. Unnecessary exposure of patients, failing to obtain explicit consent, causing harm to vulnerable or disadvantaged groups and inappropriate use of information, though normally regarded as unacceptable professional practices, may go unrecognised in meeting educational needs, widening rather than narrowing theory-practice gaps.
Comparison of patients' and health care professionals' attitudes towards advance directives.
Authors: Blondeau D , Valois P , Keyserlingk E W , Hébert M , Lavoie M
Published: November 2008

OBJECTIVES: This study was designed to identify and compare the attitudes of patients and health care professionals towards advance directives. Advance directives promote recognition of the patient's autonomy, letting the individual exercise a certain measure of control over life-sustaining care and treatment in the eventuality of becoming incompetent. DESIGN: Attitudes to advance directives were evaluated using a 44-item self-reported questionnaire. It yields an overall score as well as five factor scores: autonomy, beneficence, justice, external norms, and the affective dimension. SETTING: Health care institutions in the province of Québec, Canada. Survey sample: The sampling consisted of 921 subjects: 123 patients, 167 physicians, 340 nurses and 291 administrators of health care institutions. RESULTS: Although the general attitude of each population was favourable to the expression of autonomy, multivariate analysis of variance (MANOVA) indicated that physicians attached less importance to this subscale than did other populations (p < .001). Above all, they favoured legal external norms and beneficence. Physicians and administrators also attached less importance to the affective dimension than did patients and nurses. Specifically, physicians' attitudes towards advance directives were shown to be less positive than patients' attitudes. CONCLUSION: More attention should be given to the importance of adequately informing patients about advance directives because they may not represent an adequate means for patients to assert their autonomy.
Community care--same problems, different epithet?
Authors: Glover N
Published: November 2008

A negative image of community care prevails. This method of care is perceived to be a relatively novel phenomenon and has received mixed media coverage. The negative image of community care has led to the growing belief that this care method has failed. This failure has largely been ascribed to the lack of powers available to control patients in the community and to the method's relative novelty. However, this paper contends that there are two flaws to the above assertion: first, community care is far from new, and second, the inherent problem is not the lack of powers available to control patients in the community, but, essentially, the absence of a secure and stable environment within the community.
Reply to Lebech or the ontological humility of the lawyer faced with philosophical consistency.
Authors: Byk J C
Published: November 2008

Replying to the criticisms of Lebech, the author tries, regarding the issue of embryo research, to draw a line between what could be an international legal approach and what is a philosophical ontological quest. It is then up to the reader to decide if, and how far, these two different approaches can be complementary.
Two worlds apart: religion and ethics.
Authors: Savulescu J
Published: November 2008

In a recent article entitled, Requests "for inappropriate" treatment based on religious beliefs, Orr and Genesen claim that futile treatment should be provided to patients who request it if their request is based on a religious belief. I claim that this implies that we should also accede to requests for harmful or cost-ineffective treatments based on religious beliefs. This special treatment of religious requests is an example of special pleading on the part of theists and morally objectionable discrimination against atheists. It also provides an excellent illustration of how different the practices of religion and ethics are.
Do case studies mislead about the nature of reality?
Authors: Pattison S , Dickenson D , Parker M , Heller T
Published: November 2008

This paper attempts a partial, critical look at the construction and use of case studies in ethics education. It argues that the authors and users of case studies are often insufficiently aware of the literary nature of these artefacts: this may lead to some confusion between fiction and reality. Issues of the nature of the genre, the fictional, story-constructing aspect of case studies, the nature of authorship, and the purposes and uses of case studies as "texts" are outlined and discussed. The paper concludes with some critical questions that can be applied to the construction and use of case studies in the light of the foregoing analysis.
Beware! Preimplantation genetic diagnosis may solve some old problems but it also raises new ones.
Authors: Draper H , Chadwick R
Published: November 2008

Preimplantation genetic diagnosis (PIGD) goes some way to meeting the clinical, psychological and ethical problems of antenatal testing. We should guard, however, against the assumption that PIGD is the answer to all our problems. It also presents some new problems and leaves some old problems untouched. This paper will provide an overview of how PIGD meets some of the old problems but will concentrate on two new challenges for ethics (and, indeed, law). First we look at whether we should always suppose that it is wrong for a clinician to implant a genetically abnormal zygote. The second concern is particularly important in the UK. The Human Fertilisation and Embryology Act (1990) gives clinicians a statutory obligation to consider the interests of the future children they help to create using in vitro fertilisation (IVF) techniques. Does this mean that because PIGD is based on IVF techniques the balance of power for determining the best interests of the future child shifts from the mother to the clinician?
Should doctors intentionally do less than the best?
Authors: Savulescu J
Published: November 2008

The papers of Burley and Harris, and Draper and Chadwick, in this issue, raise a problem: what should doctors do when patients request an option which is not the best available? This commentary argues that doctors have a duty to offer that option which will result in the individual affected by that choice enjoying the highest level of wellbeing. Doctors can deviate from this duty and submaximise--bring about an outcome that is less than the best--only if there are good reasons to do so. The desire to have a child which is genetically related provides little, if any, reason to submaximise. The implication for cloning, preimplantation diagnosis and embryo transfer is that doctors should only produce a clone or transfer embryos expected to enjoy a level of wellbeing which is less than that enjoyed by other children the couple could have, if there is a good reason to employ that technology. This paper sketches what might constitute a good reason to submaximise.
Genetic testing: a conceptual exploration.
Authors: Zimmern R L
Published: November 2008

This paper attempts to explore a number of conceptual issues surrounding genetic testing. It looks at the meaning of the terms, genetic information and genetic testing in relation to the definition set out by the Advisory Committee on Genetic Testing in the UK, and by the Task Force on Genetic Testing in the USA. It argues that the special arrangements that may be required for the regulation of genetic tests should not be determined by reference to the nature or technology of the test, but by considering those morally relevant features that justify regulation. Failure to do so will lead to the regulation of genetic tests that need not be regulated, and would fail to cover other tests which should be regulated. The paper also argues that there is little in the nature of the properties of gene tests, using DNA or chromosomes, that in itself justifies a special approach.
Genetics and the British insurance industry.
Authors: Cook E D
Published: November 2008

Genetics and genetic testing raise key issues for insurance and employment. Governmental and public concern galvanised the British insurance industry into developing a code of practice. The history of the development of the code, issues of genetic discrimination, access to medical information, consent and the dangers of withholding information and the impact on the equity of pooled risk are explored. Proactive steps by the Association of British Insurers suggest that moral reflection not legislation is the way forward.
Preimplantation genetic diagnosis and the 'new' eugenics.
Authors: King D S
Published: November 2008

Preimplantation genetic diagnosis (PID) is often seen as an improvement upon prenatal testing. I argue that PID may exacerbate the eugenic features of prenatal testing and make possible an expanded form of free-market eugenics. The current practice of prenatal testing is eugenic in that its aim is to reduce the numbers of people with genetic disorders. Due to social pressures and eugenic attitudes held by clinical geneticists in most countries, it results in eugenic outcomes even though no state coercion is involved. I argue that technological advances may soon make PID widely accessible. Because abortion is not involved, and multiple embryos are available, PID is radically more effective as a tool of genetic selection. It will also make possible selection on the basis of non-pathological characteristics, leading, potentially, to a full-blown free-market eugenics. For these reasons, I argue that PID should be strictly regulated.
Protective truthfulness: the Chinese way of safeguarding patients in informed treatment decisions.
Authors: Pang M C
Published: November 2008

The first part of this paper examines the practice of informed treatment decisions in the protective medical system in China today. The second part examines how health care professionals in China perceive and carry out their responsibilities when relaying information to vulnerable patients, based on the findings of an empirical study that I had undertaken to examine the moral experience of nurses in practice situations. In the Chinese medical ethics tradition, refinement [jing] in skills and sincerity [cheng] in relating to patients are two cardinal virtues that health care professionals are required to possess. This notion of absolute sincerity carries a strong sense of parental protectiveness. The empirical findings reveal that most nurses are ambivalent about telling the truth to patients. Truth-telling would become an insincere act if a patient were to lose hope and confidence in life after learning of his or her disease. In this system of protective medical care, it is arguable as to whose interests are being protected: the patient, the family or the hospital. I would suggest that the interests of the hospital and the family members who legitimately represent the patient's interests are being honoured, but at the expense of the patient's right to know.
Abandonment of terminally ill patients in the Byzantine era. An ancient tradition?
Authors: Lascaratos J , Poulakou-Rebelakou E , Marketos S
Published: November 2008

Our research on the texts of the Byzantine historians and chroniclers revealed an apparently curious phenomenon, namely, the abandonment of terminally ill emperors by their physicians when the latter realised that they could not offer any further treatment. This attitude tallies with the mentality of the ancient Greek physicians, who even in Hippocratic times thought the treatment and care of the terminally ill to be a challenge to nature and hubris to the gods. Nevertheless, it is a very curious attitude in the light of the concepts of the Christian Byzantine physicians who, according to the doctrines of the Christian religion, should have been imbued with the spirit of philanthropy and love for their fellowmen. The meticulous analysis of three examples of abandonment of Byzantine emperors, and especially that of Alexius I Comnenus, by their physicians reveals that this custom, following ancient pagan ethics, in those times took on a ritualised form without any significant or real content.
In defence of medical ethics.
Authors: Kottow M H
Published: November 2008

A number of recent publications by the philosopher David Seedhouse are discussed. Although medicine is an eminently ethical enterprise, the technical and ethical aspects of health care practices can be distinguished, therefore justifying the existence of medical ethics and its teaching as a specific part of every medical curriculum. The goal of teaching medical ethics is to make health care practitioners aware of the essential ethical aspects of their work. Furthermore, the contention that rational bioethics is a fruitless enterprise because it analyses non-rational social events seems neither theoretically tenable nor to be borne out by actual practice. Medical ethics in particular and bioethics in general, constitute a field of expertise that must make itself understandable and convincing to relevant audiences in health care.
Parental consent to publicity.
Authors: Jones R B
Published: November 2008

The problems presented by the use of named child patients and their medical histories in television, radio and newspapers is discussed. It is suggested that it is not acceptable to regard this as comparable to their participation in non-therapeutic research, and that no one, not even the parent has the authority to give consent to such use.
Beneficence in general practice: an empirical investigation.
Authors: Rogers W A
Published: November 2008

OBJECTIVES: To study and report the attitudes of patients and general practitioners (GPs) concerning the obligation of doctors to act for the good of their patients, and to provide a practical account of beneficence in general practice. DESIGN: Semi-structured interviews administered to GPs and patients. SETTING AND SAMPLE: Participants randomly recruited from an age and gender stratified list of GPs in a geographically defined region of South Australia. The sample comprised twenty-one general practitioners and seventeen patients recruited by participating GPs. RESULTS: In practice, acting for the good of the patient not only accommodates the views of patients and GPs on expertise and knowing best, but also responds to the particular details of the clinical situation. Patients had a complex understanding of the expertise necessary for medical practice, describing a contextual domain in which they were expert, and which complemented the scientific expertise of their GPs. General practitioners identified multiple sources for their expertise, of which experience was the most significant. The role of the GP included responding to individual patients and particular clinical problems and ranged from the assumption of responsibility through to the proffering of medical advice. CONCLUSION: This study found that GPs acting for the good of their patients covered a variety of GP actions and patient preferences. Beneficence was not justified by presumed patient vulnerability or the inability of patients to understand medical problems, but furthered through a recognition of the different areas of expertise contributed by both parties to the consultation.
Hospice and euthanasia in The Netherlands: an ethical point of view.
Authors: Janssens R J , ten Have H A , Zylicz Z
Published: November 2008

This contribution is a report of a two months' participant observation in a Dutch hospice. The goal of the observation was to gain an overview of moral decisions in a hospice in which euthanasia, a tolerated practice in the Netherlands, is not accepted as an option. In an introduction, the development of palliative care in the Netherlands will be briefly presented. Subsequently, various moral decisions that were taken during the participant observation are presented and analysed by means of case reports. Attention is especially drawn to decisions that directly or indirectly relate to euthanasia. These moral decisions will be clarified in the light of the philosophy behind the concept of palliative care as it has evolved since the foundation of St Christopher's Hospice, London in 1967.
Withholding/withdrawing treatment from neonates: legislation and official guidelines across Europe.
Authors: McHaffie H E , Cuttini M , Brölz-Voit G , Randag L , Mousty R , Duguet A M , Wennergren B , Benciolini P
Published: November 2008

Representatives from eight European countries compared the legal, ethical and professional settings within which decision making for neonates takes place. When it comes to limiting treatment there is general agreement across all countries that overly aggressive treatment is to be discouraged. Nevertheless, strong emphasis has been placed on the need for compassionate care even where cure is not possible. Where a child will die irrespective of medical intervention, there is widespread acceptance of the practice of limiting aggressive treatment or alleviating suffering even if death may be hastened as a result. Where the infant could be saved but the future outlook is bleak there is more debate, but only two countries have tested the courts with such cases. When it comes to the active intentional ending of life, the legal position is standard across Europe; it is prohibited. However, recognising those intractable situations where death may be lingering and unpleasant, Dutch paediatricians have reported that they do sometimes assist babies to die with parental consent. Two cases have been tried through the courts and recent official recommendations have set out standards by which such actions may be assessed.
Jehovah's Witnesses' refusal of blood: obedience to scripture and religious conscience.
Authors: Ridley D T
Published: November 2008

Jehovah's Witnesses are students of the Bible. They refuse transfusions out of obedience to the scriptural directive to abstain and keep from blood. Dr Muramoto disagrees with the Witnesses' religious beliefs in this regard. Despite this basic disagreement over the meaning of Biblical texts, Muramoto flouts the religious basis for the Witnesses' position. His proposed policy change about accepting transfusions in private not only conflicts with the Witnesses' fundamental beliefs but it promotes hypocrisy. In addition, Muramoto's arguments about pressure to conform and coerced disclosure of private information misrepresent the beliefs and practices of Jehovah's Witnesses and ignore the element of individual conscience. In short, Muramoto resorts to distortion and uncorroborated assertions in his effort to portray a matter of religious faith as a matter of medical ethical debate.
Commentary on the “Family Rule”
Authors: Alderson Priscilla
Published: November 2008

The “family rule” paper by Dr Foreman proposes a way of resolving the present uncertainty about medical law on children's consent and refusal. This commentary reviews how doctors' decisions are already well protected by English law and respected by the courts. The “family rule” appears to be likely only to complicate the already diffuse law on parental consent, and to weaken further the competent minor's position in cases of uncertainty and disagreement. It leaves the difficult questions about defining and assessing children's competence unanswered. This commentary suggests that these questions would be better resolved through professionally determined standards of good practice that respect children and parents, rather than through rules or laws.
Altruism, blood donation and public policy: a reply to Keown.
Authors: McLachlan H V
Published: November 2008

This is a continuation of and a development of a debate between John Keown and me. The issue discussed is whether, in Britain, an unpaid system of blood donation promotes and is justified by its promotion of altruism. Doubt is cast on the notions that public policies can, and, if they can, that they should, be aimed at the promotion and expression of altruism rather than of self-interest, especially that of a mercenary sort. Reflections upon President Kennedy's proposition, introduced into the debate by Keown, that we should ask not what our country can do for us but what we can do for our country is pivotal to this casting of doubt. A case is made for suggesting that advocacy along the lines which Keown presents of an exclusive reliance on a voluntary, unpaid system of blood donation encourages inappropriate attitudes towards the provision of health care. Perhaps, it is suggested, and the suggestion represents, on my part, a change of mind as a consequence of the debate, a dual system of blood provision might be preferable.
Medical humanities: an aid to ethical discussions.
Authors: Moore A R
Published: November 2008

'The ethical landscape', the title given to part of a course devised by Mr. Moore, is described in full in this paper. The whole course is a new adventure in medical education designed to help students to explore the ethical problems in the practice of medicine. The 'ethical landscape' is seen through discussion based on passages from literature depicting doctors' and patients' dilemmas. As the results summarized in the tables show, the students found the course well worth while, and thought that they had gained a new insight into the problems with which they would be confronted and also into their own personalities and those of their fellow students whom previously they had only known superficially. The Chairman of the course, Mr. Moore, was also subjected to assessment from his students, because on the skill of the Chairman such a course would fail or succeed.
Do drug advertisements provide therapeutic information?
Authors: Stimson G V
Published: November 2008

In this study of advertisements appearing in medical periodicals and by direct mail advertising to general practitioners, Dr. Stimson, a sociologist, concludes that from what is intended to provide therapeutic information hardly any therapeutic information is provided. He reminds the reader of the safeguards which surround all drug advertising by law and by the code of practice of the Association of the British Pharmaceutical Industry but these safeguards do not appear to control real or potential sins of omission. Frequently in these advertisements the literature relating to the drug is quoted but Dr. Stimson found that it was difficult to trace all the papers quoted in different types of medical library. (Some references quoted were to unpublished papers but surely the blame should be shared in this situation?) Dr. Stimson also gives a vivid and fascinating glimpse of what he calls the 'images and stereotypes' of the patients who, it is claimed, would benefit from the drug being advertised. Certainly most general practitioners must be aware that when they prescribe that image is displaced by an individual but the portrait gallery is indeed depressing. However, to balance these advertisements drug companies issue data sheets which must be more informative than advertisements and conform to regulations in their format. Unfortunately data sheets are only issued every 15 months whereas the 'average general practitioner is potentially exposed to 1,300 advertisements every month'. In other words, the data sheet and not the advertisement should be the guideline but it arrives too infrequently to offset the lack of therapeutic information contained in advertisements.
Tacit components of medical ethics: making decisions in the clinic.
Authors: Churchill L R
Published: November 2008

When a patient visits his doctor there is, as well as a spoken dialogue, also an unspoken, or tacit, dialogue between them. This may not be evident unless that dialogue breaks down when the psychological or moral terms of reference of each are seen to be different. The author of this paper tries to elucidate the framework in which physician and patient think, and in so doing allow an understanding of why the physician may appear to be rigid and authoritarian in his dealing with his patients and the patient uncooperative.
The meaning of sex: A view from the agony column
Authors: Rayner Claire
Published: November 2008

This is a slightly edited version of a talk given by Mrs Claire Rayner, a journalist and broadcaster, to a conference on human sexuality held under the auspices of the London Medical Group in the spring of this year. Mrs Rayner's lively presentation conveys the problems and anxieties which people face in this area, even in this so-called `permissive' age.
The teaching of medical ethics at Southampton University Medical School.
Authors: Dennis K J , Hall M R
Published: November 2008

For centuries medical schools in Britain and elsewhere had a fairly static curriculum based on what might be called the 'three Rs' of medicine, and consequently had to make room for new subjects as the need arose in a fashion which was sometimes makeshift. However, Southampton University has only had a medical school for six years, and therefore their course on medical ethics and legal medicine was carefully integrated into the curriculum after some preliminary experiments carried out by a subcommittee which is continually reviewing the situation. Medical ethics has now a definite place in the fourth year, preceded by an introduction to ethical problems encountered in medicine in the first year. Not only do members of the medical faculty participate in this teaching but also members of the faculties of law and the arts.
Incest.
Authors: Nobel M
Published: November 2008

This paper is based on two presentations under the auspices of thf Edinburgh Medical Group in 1976. Dr Noble and Professor Mason, explore the incidence of incest and society's attitudes to it from legal, anthropological, medical and social viewpoints. They place this in a world context by looking at the universal prohibition of incest and the theories related to that taboo. In conclusion, they suggest that there seem to be sufficient sensible grounds on which to base a reappraisal of attitudes to incest. Their conclusions are in turn appraised by brief commentaries from a moral philospher and a psychiatrist.
When consent is unbearable--a case report.
Authors: Kottow M H
Published: November 2008

Informed consent has become one of the central problems in medical ehtics. At first sight, it would seem that no argument can be made against a person's right to be fully aware of the extent, course, and implications of his medical condition. It seems equally obvious that it is the patient's right to participate in, influence, or fully and solely assume the decisions of medical actions that should be undertaken or withheld with regard to his disease. Nevertheless, there are circumstances in which these commonly held assumptions about a patient's rights may not apply. It is the purpose of this report to describe a case where informed consent was deliverately not sought, and to discuss the ethical issues involved.
Testing new drugs--the human volunteer.
Authors: Vere D W
Published: November 2008

Professor Duncan Vere lays before us the idealised guidelines used for recruiting volunteers on which to try and test new medicines. He points out that if these were followed rigidly, few, if any volunteers would be found for this vital work. Inducements are used, but the size of these determines whether society deems it right or wrong. However, the aim is to help and advise volunteers of the need for such tests and the risks involved and therefore the information leaflet reprinted as part of the article indicates how the drug testers are attempting to encourage volunteers in as ethical a way as possible. To abandon human tests with new drugs may be unethical. A balance is sought.
The value of clinics for the relief of chronic pain.
Authors: Swerdlow M
Published: November 2008

This paper is another of the papers presented at a conference on Pain organised under the auspices of the London Medical Group. Mark Swerdlow deals with the work of pain relief clinics and explores their value. He gives the background as to what these clinics are, describes who is treated, how they are staffed and finally offers his opinion as to their effectiveness.