bluuebunny/crossref_metadata_2025 huggingface dataset:
The brain-mind quiddity: ethical issues in the use of human brain tissue for therapeutic and scientific purposes.
Authors: Burd L , Gregory J M , Kerbeshian J
Published: November 2008

The use of human brain tissue in neuroscience research is increasing. Recent developments include transplanting neural tissue, growing or maintaining neural tissue in laboratories and using surgically removed tissue for experimentation. Also, it is likely that in the future there will be attempts at partial or complete brain transplants. A discussion of the ethical issues of using human brain tissue for research and brain transplantation has been organized around nine broadly defined topic areas. Criteria for human brain tissue transplantation and laboratory use of brain tissue are proposed.
Ethics committees, principles and consequences.
Authors: Häyry M
Published: November 2008

When ethics committees evaluate the research proposals submitted to them by biomedical scientists, they can seek guidance from laws and regulations, their own beliefs, values and experiences, and from the theories of philosophers. The starting point of this paper is that philosophers can only be helpful to the members of ethics committees if they take into account in their models both the basic moral intuitions that most of us share and the consequences of people's choices. A moral view which can be labelled as a consequentialist interpretation of mid-level principlism is developed, defended and applied to some real-life and hypothetical research proposals.
Imaginary restrictions.
Authors: Pickering N
Published: November 2008

The role of literature and imagination in medicine and medical ethics is currently under discussion. This paper argues that the role of literature is not to furnish generalisable examples for guidance. Rather, engagement with literature parallels moral engagement with other people. The work of the imagination, in this context, is not to hypothesise, but to grant life to the characters and world of literature. In doing this, one may develop one's moral life.
Ethical dilemmas in occupational therapy and physical therapy: a survey of practitioners in the UK National Health Service.
Authors: Barnitt R
Published: November 2008

OBJECTIVES: To identify ethical dilemmas experienced by occupational and physical therapists working in the UK National Health Service (NHS). To compare ethical contexts, themes and principles across the two groups. DESIGN: A structured questionnaire was circulated to the managers of occupational and physical therapy services in England and Wales. SUBJECTS: The questionnaires were given to 238 occupational and 249 physical therapists who conformed to set criteria. RESULTS: Ethical dilemmas experienced during the previous six months were reported by 118 occupational and 107 physical therapists. The two groups were similar in age, grade, and years of experience. Fifty of the occupational therapy dilemmas occurred in mental health settings but no equivalent setting emerged for physical therapy. Different ethical themes emerged between the two groups, with the most common in occupational therapy being difficult/dangerous behaviour in patients and unprofessional staff behaviour, and for physical therapists resource limitations and treatment effectiveness. No differences were found in the ethical principles used. CONCLUSION: The ethical dilemmas reported by the therapists were primarily concerned with health care ethics, rather than the more dramatic ethics reported in much of the biomedical ethics literature. Differences were found between the two professional groups when ethical contexts and themes were compared but not when ethical principles were compared. This suggests that educators and researchers need to be aware of work settings and the interdisciplinary nature of employment as well as ethical principles held by individual therapists.
The scope for the involvement of patients in their consultations with health professionals: rights, responsibilities and preferences of patients.
Authors: Buetow S
Published: November 2008

The degree and nature of patient involvement in consultations with health professionals influences problem and needs recognition and management, and public accountability. This paper suggests a framework for understanding the scope for patient involvement in such consultations. Patients are defined as co-producers of formal health services, whose potential for involvement in consultations depends on their personal rights, responsibilities and preferences. Patients' rights in consultations are poorly defined and, in the National Health Service (NHS), not legally enforceable. The responsibilities of patients are also undefined. I suggest that these are not to deny, of their own volition, the rights of others, which in consultations necessitate mutuality of involvement through information-exchange and shared decision-making. Preferences should be met insofar as they do not militate against responsibilities and rights.
Natural deaths while driving: would screening for risk be ethically justified?
Authors: Cheng L H , Whittington R M
Published: November 2008

OBJECTIVES: To determine the epidemiology and the underlying pathological conditions of natural deaths among motor vehicle drivers. Sudden death while driving may cause damage to properties, other vehicles or road users. Although the Medical Commission on Accident Prevention recommended restrictions to drivers at risk of sudden death due to their medical conditions, these restrictions are useless if they do not result in greater safety to the public. DESIGN: A retrospective study of natural deaths of motor vehicle drivers. SETTING: Natural deaths of motor vehicle drivers reported to the coroner for Birmingham and Solihull. SUBJECTS: 86 consecutive natural deaths of motor vehicle drivers in a five-year period between 1984 and 1988. RESULTS: Of the 86 fatalities reviewed, 80 (93%) sudden deaths were caused by ischaemic heart disease. Fifty vehicles were involved in collision with 32 properties, 20 other vehicles and six pedestrians. Fifty-one out of 80 cardiac deaths had past cardiac history and three had reported chest pain prior to the sudden death. CONCLUSION: An applied normative ethical assessment based on the basic moral principles of autonomy, justice, beneficence and non-maleficence are discussed. We conclude that medical screening of drivers has little benefit for the drivers or other persons.
The role of futility judgments in improperly limiting the scope of clinical research.
Authors: Harper W
Published: November 2008

In medical research, the gathering and presenting of data can be limited in accordance with the futility judgments of the researchers. In that case, research results falling below the threshold of what the researchers deem beneficial would not to be reported in detail. As a result, the reported information would tend to be useful only to those who share the valuational assumptions of the researchers. Should this practice become entrenched, it would reduce public confidence in the medical establishment, aggravate factionalism within the research community, and unduly influence treatment decisions. I suggest alternative frameworks for measuring survival outcomes.
Pressuring Mrs Thomas to accept treatment: a case history.
Authors: Hurwitz B
Published: November 2008

A general practitioner (GP) recounts events which unfolded after visiting a patient at home. She was found to be suffering from an entirely curable clinical condition which was worsening as a result of refusal to accept effective medical treatment. The effects upon a grown-up son of the patient's refusal, and the increasing burden of care falling upon local district nursing services, were factors which influenced the GP's thinking and decision making.
Pulling up the runaway: the effect of new evidence on euthanasia's slippery slope.
Authors: Ryan C J
Published: November 2008

The slippery slope argument has been the mainstay of many of those opposed to the legalisation of physician-assisted suicide and euthanasia. In this paper I re-examine the slippery slope in the light of two recent studies that examined the prevalence of medical decisions concerning the end of life in the Netherlands and in Australia. I argue that these two studies have robbed the slippery slope of the source of its power--its intuitive obviousness. Finally I propose that, contrary to the warnings of the slippery slope, the available evidence suggests that the legalisation of physician-assisted suicide might actually decrease the prevalence of non-voluntary and involuntary euthanasia.
Comment on a proposed draft protocol for the European Convention on Biomedicine relating to research on the human embryo and fetus.
Authors: Lebech M M
Published: November 2008

Judge Christian Byk renders service to the Steering Committee on Bioethics of the Council of Europe (CDBI) by proposing a draft of the protocol destined to fill in a gap in international law on the status of the human embryo. This proposal, printed in a previous issue of the Journal of Medical Ethics deserves nevertheless to be questioned on important points. Is Christian Byk proposing to legalise research on human embryos not only in vitro but also in utero?
'Wrongful life' lawsuits for faulty genetic counselling: should the impaired newborn be entitled to sue?
Authors: Shapira A
Published: November 2008

A "wrongful life" suit is based on the purported tortious liability of a genetic counsellor towards an infant with hereditary defects, with the latter asserting that he or she would not have been born at all if not for the counsellor's negligence. This negligence allegedly lies in the failure on the part of the defendant adequately to advice the parents or to conduct properly the relevant testing and thereby prevent the child's conception or birth (where unimpaired life was not possible). This paper will offer support for the thesis that it would be both feasible and desirable to endorse "wrongful life" compensation actions. The genetic counsellor owed a duty of due professional care to the impaired newborn who now claims that but for the counsellor's negligence, he or she would not have been born at all. The plaintiff's defective life (where healthy life was never an option) constitutes a compensable injury. A sufficient causal link may exist between the plaintiff's injury and the defendant's breach of duty of due professional care and an appropriate measure of damages can be allocated to the disabled newborn. Sanctioning a "wrongful life" cause of action does not necessarily entail abandoning valuable constraints with regard to abortion and euthanasia. Nor does it inevitably lead to an uncontrolled slide down a "slippery slope".
Does pregnancy affect medical ethical decision making?
Authors: Hammerman C , Lavie O , Kornbluth E , Rabinson J , Schimmel M S , Eidelman A I
Published: November 2008

OBJECTIVE: We studied and compared the attitudes of pregnant women v new mothers in an attempt to confirm changing patterns of maternal response towards medical ethical decision making in critically ill or malformed neonates. DESIGN: Data were obtained by questionnaires divided into three sections: 1. sociodemographic; 2. Theoretical principles which might be utilised in the decision-making process; 3. Hypothetical case scenarios, each followed by possible treatment options. RESULTS: Pregnant women (n = 545) consistently requested less aggressive medical intervention for the hypothetical cases than did new mothers (n = 250) [Trisomy 18: 57% v 42%; p = 0.0004; Asphyxia: 75% v 63%; p = 0.0017; Down's syndrome 81% v 62%; p = 0.0001; LBW 85% v 75%; p = 0.004]. Significant differences were also observed in the responses to the theoretical principles, with pregnant women attributing less importance to preserving life at all cost, while being more concerned with physical and emotional pain and suffering, with financial cost, and with the infant's potential for future productivity.
Voluntary euthanasia under control? Further empirical evidence from The Netherlands.
Authors: Jochemsen H , Keown J
Published: November 2008

Nineteen ninety-six saw the publication of a major Dutch survey into euthanasia in the Netherlands. This paper outlines the main statistical findings of this survey and considers whether it shows that voluntary euthanasia is under effective control in the Netherlands. The paper concludes that although there has been some improvement in compliance with procedural requirements, the practice of voluntary euthanasia remains beyond effective control.
Slippery slopes in flat countries--a response.
Authors: van Delden J J
Published: November 2008

In response to the paper by Keown and Jochemsen in which the latest empirical data concerning euthanasia and other end-of-life decisions in the Netherlands is discussed, this paper discusses three points. The use of euthanasia in cases in which palliative care was a viable alternative may be taken as proof of a slippery slope. However, it could also be interpreted as an indication of a shift towards more autonomy-based end-of-life decisions. The cases of non-voluntary euthanasia are a serious problem in the Netherlands and they are only rarely justifiable. However, they do not prove the existence of a slippery slope. Persuading the physician to bring euthanasia cases to the knowledge of the authorities is a problem of any euthanasia policy. The Dutch notification procedure has recently been changed to reduce the underreporting of cases. However, many questions remain.
Conditions required for a law on active voluntary euthanasia: a survey of nurses' opinions in the Australian Capital Territory.
Authors: Kitchener B , Jorm A F
Published: November 2008

OBJECTIVES: To ascertain which conditions nurses believe should be in a law allowing active voluntary euthanasia (AVE). DESIGN: Survey questionnaire posted to registered nurses (RNs). SETTING: Australian Capital Territory (ACT) at the end of 1996, when active voluntary euthanasia was legal in the Northern Territory. SURVEY SAMPLE: A random sample of 2,000 RNs, representing 54 per cent of the RN population in the ACT. MAIN MEASURES: Two methods were used to look at nurses' opinions. The first involved four vignettes which varied in terms of critical characteristics of each patient who was requesting help to die. The respondents were asked if the law should be changed to allow any of these requests. There was also a checklist of conditions, most of which have commonly been included in Australian proposed laws on AVE. The respondents chose those which they believed should apply in a law on AVE. RESULTS: The response rate was 61%. Support for a change in the law to allow AVE was 38% for a young man with AIDS, 39% for an elderly man with early stage Alzheimer's disease, 44% for a young woman who had become quadriplegic and 71% for a middle-aged woman with metastases from breast cancer. The conditions most strongly supported in any future AVE law were: "second doctor's opinion", "cooling off period", "unbearable protracted suffering", "patient fully informed about illness and treatment" and "terminally ill". There was only minority support for "not suffering from treatable depression", "administer the fatal dose themselves" and "over a certain age". CONCLUSION: Given the lack of support for some conditions included in proposed AVE laws, there needs to be further debate about the conditions required in any future AVE bills.
Assessment of physician-assisted death by members of the public prosecution in The Netherlands.
Authors: Cuperus-Bosma J M , van der Wal G , Looman C W , van der Maas P J
Published: November 2008

OBJECTIVES: To identify the factors that influence the assessment of reported cases of physician-assisted death by members of the public prosecution. DESIGN/SETTING: At the beginning of 1996, during verbal interviews, 12 short case-descriptions were presented to a representative group of 47 members of the public prosecution in the Netherlands. RESULTS: Assessment varied considerably between respondents. Some respondents made more "lenient" assessments than others. Characteristics of the respondents, such as function, personal-life philosophy and age, were not related to the assessment. Case characteristics, i.e. the presence of an explicit request, life expectancy and the type of suffering, strongly influenced the assessment. Of these characteristics, the presence or absence of an explicit request was the most important determinant of the decision whether or not to hold an inquest. CONCLUSIONS: Although the presence of an explicit request, life expectancy and the type of suffering each influenced the assessment, each individual assessment was dependent on the assessor. The resulting danger of legal inequality and legal uncertainty, particularly in complicated cases, should be kept to a minimum by the introduction of some form of protocol and consultation in doubtful or boundary cases. The notification procedure already promotes a certain degree of uniformity in the prosecution policy.
Human cloning and child welfare.
Authors: Burley J , Harris J
Published: November 2008

In this paper we discuss an objection to human cloning which appeals to the welfare of the child. This objection varies according to the sort of harm it is expected the clone will suffer. The three formulations of it that we will consider are: 1. Clones will be harmed by the fearful or prejudicial attitudes people may have about or towards them (H1); 2. Clones will be harmed by the demands and expectations of parents or genotype donors (H2); 3. Clones will be harmed by their own awareness of their origins, for example the knowledge that the genetic donor is a stranger (H3). We will show why these three versions of the child welfare objection do not necessarily supply compelling reasons to ban human reproductive cloning. The claim that we will develop and defend in the course of our discussion is that even if it is the case that a cloned child will suffer harms of the type H1-H3, it is none the less permissible to conceive by cloning so long as these cloning-induced welfare deficits are not such as to blight the existence of the resultant child, whoever this may be.
Does justice require genetic enhancements?
Authors: Holtug N
Published: November 2008

It is argued that justice in some cases provides a pro tanto reason genetically to enhance victims of the genetic lottery. Various arguments--both to the effect that justice provides no such reason and to the effect that while there may be such reasons, they are overridden by certain moral constraints--are considered and rejected. Finally, it is argued that justice provides stronger reasons to perform more traditional medical tasks (treatments), and that therefore genetic enhancements should not play an important role in a public health care system.
Prenatal diagnosis and discrimination against the disabled.
Authors: Gillam L
Published: November 2008

Two versions of the argument that prenatal diagnosis discriminates against the disabled are distinguished and analysed. Both are shown to be inadequate, but some valid concerns about the social effects of prenatal diagnosis are highlighted.
The social nature of disability, disease and genetics: a response to Gillam, Persson, Holtug, Draper and Chadwick.
Authors: Newell C
Published: November 2008

The dominance of the biomedically informed view of disability, genetics, and diagnosis is explored. An understanding of the social nature of disability and genetics, especially in terms of oppression, adds a richer dimension to an understanding of ethical issues pertaining to genetics. This is much wider than the limited question of whether or not such technology discriminates. Instead, it is proposed that such technology will perpetuate the oppression and control of people with disability, especially if the knowledge of people with disability is not utilised in bioethical debates.
Beyond the disorder: one parent's reflection on genetic counselling.
Authors: McGowan R
Published: November 2008

As a mother of two sons with adrenoleukodystrophy the author of this paper writes about her experiences of genetic counselling following the diagnosis. She discusses the dilemmas, emotions and aftermath this knowledge has brought to her family and the roles she played. Personal concerns are raised about the values guiding genetic counselling which, she found, focused on the technical details without considering the ethical implications arising from the new knowledge or the emotional dilemmas of prenatal testing. Some consequences of choice and the value of hope are discussed. She concludes by challenging genetic counsellors to deliver a service which not only provides technical information but is cognisant of the ethical considerations this information may foist upon a family.
Should we genetically test everyone for haemochromatosis?
Authors: Allen K , Williamson R
Published: November 2008

The increasing availability of DNA-based diagnostic tests has raised issues about whether these should be applied to the population at large in order to identify, treat or prevent a range of diseases. DNA tests raise concerns in the community for several reasons. There is the possibility of stigmatisation and discrimination between those who test positive and those who don't. High-risk individuals may be identified for whom no proven effective intervention is possible, or conversely may test "positive" for a disease that does not eventuate. Controversy concerning prenatal diagnosis and termination of affected pregnancies may arise. Haemochromatosis, however, is a disease that is not only treatable but also preventable if those at high risk are identified presymptomatically. This paper will identify and discuss key issues regarding DNA-based population screening for haemochromatosis, and argue that population-based genetic screening for haemochromatosis should be supported when a number of contentious issues are addressed. In the context of a health system with limited resources haemochromatosis is the paradigm of a disorder where there is an ethical and clinical imperative to encourage presymptomatic DNA testing for all in ethnically relevant communities.
Cloning, killing, and identity.
Authors: McMahan J
Published: November 2008

One potentially valuable use of cloning is to provide a source of tissues or organs for transplantation. The most important objection to this use of cloning is that a human clone would be the sort of entity that it would be seriously wrong to kill. I argue that entities of the sort that you and I essentially are do not begin to exist until around the seventh month of fetal gestation. Therefore to kill a clone prior to that would not be to kill someone like you or me but would be only to prevent one of us from existing. And even after one of us begins to exist, the objections to killing it remain comparatively weak until its psychological capacities reach a certain level of maturation. These claims support the permissibility of killing a clone during the early stages of its development in order to use its organs for transplantation.
Should we clone human beings? Cloning as a source of tissue for transplantation.
Authors: Savulescu J
Published: November 2008

The most publicly justifiable application of human cloning, if there is one at all, is to provide self-compatible cells or tissues for medical use, especially transplantation. Some have argued that this raises no new ethical issues above those raised by any form of embryo experimentation. I argue that this research is less morally problematic than other embryo research. Indeed, it is not merely morally permissible but morally required that we employ cloning to produce embryos or fetuses for the sake of providing cells, tissues or even organs for therapy, followed by abortion of the embryo or fetus.
Responses by four Local Research Ethics Committees to submitted proposals.
Authors: Kent G
Published: November 2008

BACKGROUND: There is relatively little research concerning the processes whereby Local Research Ethics Committees discharge their responsibilities towards society, potential participants and investigators. OBJECTIVES: To examine the criteria used by LRECs in arriving at their decisions concerning approval of research protocols through an analysis of letters sent to investigators. DESIGN: Four LRECs each provided copies of 50 letters sent to investigators after their submitted proposals had been considered by the committees. These letters were subjected to a content analysis, in which specific comments and requests for additional information and changes in the protocols were recorded and compared. FINDINGS: Overall 24% of proposals were approved without request for changes or clarifications, but this varied by committee: one committee approved only 6% of proposals without change or clarification while the others ranged from 26% to 32%. The content analyses of responses indicated that they could be placed into four categories: (i) further information for the committee to aid in their deliberations; (ii) requests for changes to the design or justification for the design used; (iii) changes to the information sheets provided to potential participants; and (iv) changes to consent procedures. Of these, alterations to information sheets were the most common type of request. These four types of response could be seen as safeguarding the wellbeing of potential participants (the principle of non-maleficence), of promoting the scientific validity of the research (the principle of beneficence), and of enhancing the rights of potential participants (the principle of autonomy). CONCLUSIONS: The committees were consistent in the types of requests they made of investigators, which can be seen as attempts to protect participants' rights and ensure the scientific validity of studies. Without an analysis of the proposals sent to the committees, however, it is difficult to account for the variation in the requirements set by the committees before approval was given.
Family consent, communication, and advance directives for cancer disclosure: a Japanese case and discussion.
Authors: Akabayashi A , Fetters M D , Elwyn T S
Published: November 2008

The dilemma of whether and how to disclose a diagnosis of cancer or of any other terminal illness continues to be a subject of worldwide interest. We present the case of a 62-year-old Japanese woman afflicted with advanced gall bladder cancer who had previously expressed a preference not to be told a diagnosis of cancer. The treating physician revealed the diagnosis to the family first, and then told the patient: "You don't have any cancer yet, but if we don't treat you, it will progress to a cancer". In our analysis, we examine the role of family consent, communication patterns (including ambiguous disclosure), and advance directives for cancer disclosure in Japan. Finally, we explore the implications for Edmund Pellegrino's proposal of "something close to autonomy" as a universal good.
Survey of Japanese physicians' attitudes towards the care of adult patients in persistent vegetative state.
Authors: Asai A , Maekawa M , Akiguchi I , Fukui T , Miura Y , Tanabe N , Fukuhara S
Published: November 2008

OBJECTIVES: Ethical issues have recently been raised regarding the appropriate care of patients in persistent vegetative state (PVS) in Japan. The purpose of our study is to study the attitudes and beliefs of Japanese physicians who have experience caring for patients in PVS. DESIGN AND SETTING: A postal questionnaire was sent to all 317 representative members of the Japan Society of Apoplexy working at university hospitals or designated teaching hospitals by the Ministry of Health and Welfare. The questionnaire asked subjects what they would recommend for three hypothetical vignettes that varied with respect to a PVS patient's previous wishes and the wishes of the family. RESULTS: The response rate was 65%. In the case of a PVS patient who had no previous expressed wishes and no family, 3% of the respondents would withdraw artificial nutrition and hydration (ANH) when the patient did not require any other life-sustaining treatments, 4% would discontinue ANH, and 30% would withhold antibiotics when the patient developed pneumonia. Significantly more respondents (17%) would withdraw ANH in the case of a PVS patient whose previous wishes and family agreed that all life support be discontinued. Most respondents thought that a patient's written advance directives would influence their decisions. Forty per cent of the respondents would want to have ANH stopped and 31% would not want antibiotics administered if they were in PVS. CONCLUSIONS: Japanese physicians tend not to withdraw ANH from PVS patients. Patients' written advance directives, however, would affect their decisions.
The status of the do-not-resuscitate order in Chinese clinical trial patients in a cancer centre.
Authors: Liu J M , Lin W C , Chen Y M , Wu H W , Yao N S , Chen L T , Whang-Peng J
Published: November 2008

OBJECTIVE: To report and analyse the pattern of end-of-life decision making for terminal Chinese cancer patients. DESIGN: Retrospective descriptive study. SETTING: A cancer clinical trials unit in a large teaching hospital. PATIENTS: From April 1992 to August 1997, 177 consecutive deaths of cancer clinical trial patients were studied. MAIN MEASUREMENT: Basic demographic data, patient status at the time of signing a DNR consent, or at the moment of returning home to die are documented, and circumstances surrounding these events evaluated. RESULTS: DNR orders were written for 64.4% of patients. Patients in pain (odds ratio 0.45, 95% CI 0.22-0.89), especially if requiring opioid analgesia (odds ratio 0.40, 95% CI 0.21-0.77), were factors associated with a higher probability of such an order. Thirty-five patients were taken home to die, a more likely occurrence if the patient was over 75 years (odds ratio 0.12, 95% CI 0.04-0.34), had children (odds ratio 0.14, 95% CI 0.02-0.79), had Taiwanese as a first language (odds ratio 6.74, 95% CI 3.04-14.93), or was unable to intake orally (odds ratio 2.73, 95% CI 1.26-5.92). CPR was performed in 30 patients, none survived to discharge. CONCLUSIONS: DNR orders are instituted in a large proportion of dying Chinese cancer patients in a cancer centre, however, the order is seldom signed by the patient personally. This study also illustrates that as many as 20% of dying patients are taken home to die, in accordance with local custom.
Camouflage is no defence--a response to Kottow.
Authors: Seedhouse D
Published: November 2008

The author responds to Professor Kottow's criticisms, explaining numerous errors and misconceptions.
A reply to Professor Seedhouse.
Authors: Kottow Michael H
Published: November 2008

This brief reply gives a few references and clarifies some points in order to emphasize that a number of Professor Seedhouse's assertions are debatable and that his criticism of slovenly scholarship and his unbridled ad hominem argumentation are out of place and easily refuted.
Attitudes of the Lebanese public regarding disclosure of serious illness.
Authors: Adib S M , Hamadeh G N
Published: November 2008

OBJECTIVES: To measure the preference regarding disclosure of a serious diagnosis, and its determinants, of the Lebanese public. DESIGN AND SETTING: Non-random sample survey of 400 persons interviewed in health care facilities in Beirut in 1995. RESULTS: Forty-two per cent of respondents generally preferred truth not to be disclosed directly to patients. Preference for disclosure was associated with younger age, better education and tendency to rapport-building with physicians. There were no meaningful associations between place of residence (urban/rural), level of religious practice, or religious affiliation, and preference for disclosure. CONCLUSIONS: Under one plausible interpretation, this survey suggests that the expectation for concealment will decrease as the advantage of knowledge in better coping with disease is understood by an increasingly better educated public, and that the Lebanese public will increasingly come to expect direct and full disclosure of serious diagnoses.
Bioethics regulations in Turkey.
Authors: Aydin E
Published: November 2008

Although modern technical and scientific developments in medicine are followed closely in Turkey, it cannot be claimed that the same is true in the field of bioethics. Yet, more and more attention is now being paid to bioethics and ethics training in health sciences. In addition, there are also legal regulations in bioethics, some of which are not so new. The objective of these regulations is to provide technical and administrative control. Ethical concerns are rather few. What attracts our attention most in these regulations is the presence of the idea of "consent".
'He is too young to die ... and you too, doctor'.
Authors: Knecht J
Published: November 2008

Sometimes caregiving can be a matter of fear rather than of love.
Food refusal in prisoners: a communication or a method of self-killing? The role of the psychiatrist and resulting ethical challenges.
Authors: Brockman B
Published: November 2008

Food refusal occurs for a variety of reasons. It may be used as a political tool, as a method of exercising control over others, at either the individual, family or societal level, or as a method of self-harm, and occasionally it indicates possible mental illness. This article examines the motivation behind hunger strikes in prisoners. It describes the psychiatrist's role in assessment and management of prisoners by referring to case examples. The paper discusses the assessment of an individual's competence to commit suicide by starvation, legal restraints to intervention, practical difficulties and associated ethical dilemmas. Anecdotal evidence suggests that most prisoners who refuse food are motivated by the desire to achieve an end rather than killing themselves, and that hunger-strike secondary to mental illness is uncommon. Although rarely required, the psychiatrist may have an important contribution to make in the management of practical and ethical difficulties.
Autonomy, rationality and the wish to die.
Authors: Clarke D M
Published: November 2008

Although suicide has traditionally carried a negative sanction in Western societies, this is now being challenged, and while there remains substantial public concern surrounding youth and elder suicide, there is a paradoxical push to relax the prohibition under certain circumstances. Central to the arguments behind this are the principles of respect for autonomy and the importance of rationality. It is argued here that the concepts of rationality and autonomy, while valuable, are not strong enough to substantiate a categorical "right to suicide" and that the concepts of "understandability" and "respect" are more useful and able to provide the foundation for responding to a person expressing a wish to die. Roman suicide, sometimes held as an example of "rational suicide", illustrates the effects of culture, tradition and values on the attitudes to, and the practice of, suicide.
Arguments for zero tolerance of sexual contact between doctors and patients.
Authors: Cullen R M
Published: November 2008

Some doctors do enter into sexual relationships with patients. These relationships can be damaging to the patient involved. One response available to both individual doctors and to disciplinary bodies is to prohibit sexual contact between doctors and patients ("zero tolerance"). This paper considers five ways of arguing for a zero tolerance policy. The first rests on an empirical claim that such contact is almost always harmful to the patient involved. The second is based on a "principles" approach while the third originates in "virtues" ethics. The fourth argues that zero tolerance is an "a priori" truth. These four attempt to establish that the behaviour is always wrong and ought, therefore, to be prohibited. The fifth argument is counterfactual. It claims a policy that allowed sexual contact would have unacceptable consequences. Given the responsibility of regulatory bodies to protect the public, zero tolerance is a natural policy to develop.
The family rule: a reply to Alderson
Authors: Foreman D M
Published: November 2008

In her commentary, Alderson makes four major criticisms of the family rule. She claims that: consent must be explicit; that consenting parties should be reasonably equal; that the concept of a family rule adds little to current understanding, and that the effect of applying the concept in practice will be to impair the consenting process. However, there are other important examples of implicit consent in daily life, and consent between unequals is common and unexceptionable. The family rule establishes an unequivocal ethical base for the role of children, parents and practitioners in the consenting process, which is sorely needed. This base structures practitioners' interventions towards children in an appropriately empowering manner. Therefore, Alderson's critical objections fail.
Autonomy, liberalism and advance care planning.
Authors: Ikonomidis S , Singer P A
Published: November 2008

The justification for advance directives is grounded in the notion that they extend patient autonomy into future states of incompetency through patient participation in decision making about end-of-life care. Four objections challenge the necessity and sufficiency of individual autonomy, perceived to be a defining feature of liberal philosophical theory, as a basis of advance care planning. These objections are that the liberal concept of autonomy (i) implies a misconception of the individual self, (ii) entails the denial of values of social justice, (iii) does not account for justifiable acts of paternalism, and (iv) does not account for the importance of personal relationships in the advance care planning process. The last objection is especially pertinent in light of recent empirical research highlighting the importance of personal relationships in advance care planning. This article examines these four objections to autonomy, and the liberal theoretical framework with which it is associated, in order to re-evaluate the philosophical basis of advance care planning. We argue that liberal autonomy (i) is not a misconceived concept as critics assume, (ii) does not entail the denial of values of social justice, (iii) can account for justifiable acts of paternalism, though it (iv) is not the best account of the value of personal relationships that arise in advance care planning. In conclusion, we suggest that liberalism is a necessary component of a theoretical framework for advance care planning but that it needs to be supplemented with theories that focus explicitly on the significance of personal relationships.
On dying and dying well: Extracts from the Edwin Stevens lecture
Authors: Coggan Donald
Published: November 2008

The idea of a happy death is one that startles and disgusts modern man. However, although that phrase is not often used today, that is what the Archbishop of Canterbury, Dr Donald Coggan, is to some extent considering in his Edwin Stevens lecture given to the Royal Society of Medicine. We are publishing extracts from that lecture by kind permission of the President of the Royal Society of Medicine. We have chosen those passages in the lecture which discuss the limits of the doctor's responsibility to keep a patient alive, the erroneous idea that Christians believe in the artificial prolongation of life in all circumstances, and the most delicate question of the choice of patients who shall receive the costly benefits of modern medical technology.
The literature of medical ethics: Bernard Häring
Authors: Soane Brendan
Published: November 2008

To the general reader and watcher of television programmes medical ethics may appear to be something new. This is not so, for hundreds of articles and many books have appeared over the last 10 years or so to discuss and analyse the problems arising from the practice of medicine. In this study of two larger works -Medical EthicsandManipulation- both by Bernard Häring, a Roman Catholic theologian - Father Brendan Soane analyses these in some detail and sets their ideas in the context of what has already been written on the major issues of medical ethics and what is likely to be foremost in discussion in the near future. Many readers of this Journal already have the particular background of knowledge to see the problems in medicine which are in fact ethical but the general reader may require help and enlightenment and this is now provided for a special field within the field.
The General Medical Council: frame of reference or arbiter of morals?
Authors: Hill D
Published: November 2008

Many members of the public think of the General Medical Council (GMC) as the body which tries doctors: the doctors' law courts, as it were. And, except in the more sober of newspapers and news reports, the 'offences ' which receive the most publicity are those concerning alleged improper relations between doctors and patients. Professor Sir Denis Hill, in the following paper, which he read in the spring of this year to the annual conference of the London Medical Group devoted to a discussion of human sexuality, chose to examine the whole function of the General Medical Council as a frame of moral reference for doctors. Judging allegations of professional misconduct by doctors is the function of the Council's Disciplinary Committee. Judging sexual misconduct forms only a small part of their work. The GMC's responsibility covers the whole notion of morals and morality as it concerns doctors in their professional work. Sir Denis Hill stresses the modern thinking that morality must be learned and that attitudes are always shifting as society alters its norms of what is moral conduct. That is not to say that all that was previously considered not to be moral has now become acceptable but rather that other concepts have entered the field of moral debate. Therefore the GMC must constantly review the frame of reference it offers to doctors and the public may be surprised to learn that that process is never static. Sir Denis Hill in this paper is speaking personally and not as a member of the General Medical Council or of any of that body's special committees.
Royal College of Nursing (Rcn) code of professional conduct: a discussion document.
Authors: Dawson J D , Altschul A T , Sampson C , Smith A M
Published: November 2008

We are printing in its entirety the discussion document which sets out a code of professional conduct for nurses published by the Royal College of Nursing in November 1976 together with commentaries by the Assistant Secretary of the British Medical Association, a professor of nursing studies, student nurses and a lawyer. The image of the nurse is still that of one of Florence Nightingale's young ladies or of a member of a religious order who is wholly dedicated to caring for the sick. Today, as this document and the comments upon it show, 'dedication' is still part of the motive which leads a man or woman to become a nurse but in addition, and this is where the public may be ignorant or choose to be ignorant, nursing offers a career where intellectual achievement and the satisfaction of a demanding job bring their proper financial reward and place in the professional community. We are grateful to the Royal College of Nursing for permission to publish this document.
False belief and the refusal of medical treatment.
Authors: Faden R , Faden A
Published: November 2008

May a doctor treat a patient, despite that patient's refusal, when in his professional opinion treatment is necessary? This is the dilemma which must from time to time confront most physicians. An examination of the validity of such a refusal is provided by the present authors who use the case history of a patient refusing treatment, for cancer as well as for a fractured hip, to evaluate the grounds for intervention in such circumstances. In such a situation the patient is said to have a 'false belief' and it is the doctor's duty to try to change that belief in the patient's interest. The false belief is considered here in terms of the liberty principle, the patient's mental competence and on what is called the 'harm principle' (harm to other individuals or to society). Finally the concept of paternalism is examined. The authors conclude that the doctor must attempt to change a false belief, and if this fails he must examine the patient's mental competence to make the decision to refuse treatment. But in the last analysis the doctor may be under an obligation to respect the patient's refusal. Readers might like to look at (or read again) the papers on 'Liberty' and 'Conscience' published in this Journal under the heading Analysis.
Problems in deceptive medical procedures: an ethical and legal analysis of the administration of placebos
Authors: Simmons Beth
Published: November 2008

The use of placebos in therapy or research poses ethical questions. What are the benefits and the costs in ethical terms of condoning deception of the patient or subject? What does the deception mean for the patient's or subject's right to give informed consent to his treatment?

Doctors are rightly expected to disclose to their patient facts which would in their judgement best enable him to give informed consent to treatment. On occasion, the degree of this disclosure may be limited by the need to avoid hazarding the success of treatment of an unstable patient whose condition threatens his life, but doctors should have no right to withhold information just to prevent a patient refusing consent to therapy. No such limitation should apply in experiments wherefulldisclosure must operate to enable the subject to give his informed consent.

The potential medical benefits for the patient of placebo therapy have to be weighed against all the ethical costs of the deception and dishonesty involved, including the longer term repercussions on doctor/patient trust: similar ethical costs may arise in experiments involving the use of placebos without disclosure of this as a possibility to the subject. Deception is ethically degrading to both parties not only being a breach of trust, but denying the moral autonomy of the patient or subject to make his own choice.

The writer concludes that placebos should be used only with full disclosure and consent whether in therapy or in research, and that this need not impede the success of either.
A follow-up neurobiological study: why volunteer?
Authors: Sturges J S , Sweeney D R , Pickar D
Published: November 2008

There is usually great concern over the use of psychiatric patients for clinical research, as it raises the ethical and legal issues of human dignity and autonomy. In this paper the authors describe and evaluate a follow-up neurobiological study of patients who had been discharged from a psychiatric research ward at least ten months earlier. It is pointed out that such studies are rare and that the writers were provided with the unique opportunity to examine attitudinal and motivational dimensions involved in the patients' agreement to participate in the study.
Taboos and clinical research in West Africa.
Authors: Ajayi O O
Published: November 2008

Moral principles or the rules of conduct are based in the society. If the purpose of ethics in research is to take into consideration the needs and the rights of the experimental subject, his social milieu must then largely determine the ethical considerations of a projected study. The inability to comprehend such rights may often be due to ignorance, disease and his societal values. Blood letting, biopsy and post-mortem examinations may so conflict with local beliefs that so called 'consent' to these is much more than a surrender of the rights of the individual. It is difficult to conform with the highest principles of ethics in research in any uniform society. It is more so when the many variables are further complicated by cultural demands and social taboos. The best custodians of ethical standards must relate intimately with the norms of the local population.
Transsexualism: a legal perspective.
Authors: Thomson J M
Published: November 2008

This paper begins with a discussion of the current legal definition of sex laid down in Corbett v Corbett. The implications of this test for three areas of the law, marriage, birth certificates and employment are then examined. Solutions from the United States of America and West Germany are studied and the suitability of similar solutions being transplanted into British law discussed.