The Ethics of Medicine: An Annotated Bibliography of Recent Literature
Authors: ALBERT R. JONSEN, CHRISTINE CASSEL, BERNARD LO, HENRY S. PERKINS
Journal: Annals of Internal Medicine (1980)

The Literature of Medicine1 January 1980The Ethics of Medicine: An Annotated Bibliography of Recent LiteratureALBERT R. JONSEN, Ph.D., CHRISTINE CASSEL, M.D., BERNARD LO, M.D., HENRY S. PERKINS, M.D.ALBERT R. JONSEN, Ph.D.Search for more papers by this author, CHRISTINE CASSEL, M.D.Search for more papers by this author, BERNARD LO, M.D.Search for more papers by this author, HENRY S. PERKINS, M.D.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-92-1-136 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptThis bibliography is designed to introduce the internist and others in clinical medicine to the rapidly expanding literature in medical ethics. This field is important but controversial. Some believe there are no answers, or so many answers, to any ethical problem that might arise in medical practice that it is impossible or futile to present "ethical" information. Despite many unresolved problems, however, the extensive literature in medical ethics reveals substantial agreement about some questions. This bibliography emphasizes the literature that reports areas of agreement rather than debate. Nevertheless, since ethical decisions, like most clinical decisions, are very personal and strongly...General Works Death and Dying Informed Consent Confidentiality and Privileged Communication Patient Care Ethics of Medication Truth Telling in Disclosure Human Experimentation Justice and Health-Care Delivery1. REICH W, ed. Encyclopedia of Bioethics. New York: The Free Press; 1978. Four volumes containing excellent basic articles on almost all the issues currently being discussed in medical ethics, with ample references to broader literature in ethics, medicine, and science. Google Scholar2. BEAUCHAMPWALTERS TL, eds. Contemporary Issues in Bioethics. Encino, California: Dickenson Publishing Co.; 1978. Google Scholar3. REISERDYCKCURRAN SAW, eds. Ethics in Medicine: Historical Perspectives and Contemporary Concerns. Cambridge, Massachusetts: MIT Press; 1977. Among the dozen anthologies published in the last 5 years, these two are the most comprehensive, containing articles on the major issues by philosophers, theologians, physicians, lawyers. The second volume contains important documents from the historical development of medical ethics. Google Scholar4. WALTERS L, ed. Bibliography of Bioethics. Yearly volumes. Available from Gale Research Company, Book Tower, Detroit, MI 48226. Google Scholar5. Bibliography of Society, Ethics and the Life Sciences. Hastings-on-Hudson, New York: Institute of Society, Ethics and the Life Sciences. The two major bibliographical sources. The first, produced by the Kennedy Institute for Bioethics, Georgetown University, is also available as a computerized literature retrieval service of the National Library of Medicine (BIOETHICSLINE). The second comes from the leading center for research and public discussion of bioethical issues, the Hastings Center, which also publishes the monthly Hastings Center Report containing many important articles. Google Scholar6. BEAUCHAMPCHILDRESS TJ. Principles of Biomedical Ethics. New York: Oxford University Press; 1979. A clear, concise textbook explaining basic ethical principles and showing how they are applied to major issues in bioethics, such as informed consent, risk-benefit assessment, confidentiality, and decisions to terminate therapy. Google Scholar7. RAMSEY P. The Patient as Person. New Haven: Yale University Press; 1970. Difficult to read, but a provocative early contribution analyzing many ethical issues facing the physician. Google Scholar8. CAMPBELL A. Moral Dilemmas in Medicine. Edinburgh: Churchill-Livingstone; 1975. Brief, with many clinical examples, but perhaps too rigid in analysis of the problems presented. Google Scholar9. PELLEGRINO E. Medical ethics, education and the physician's image. JAMA. 1976;235:1043-4. Editorial. CrossrefMedlineGoogle Scholar10. PELLEGRINO E. Ethics and the moment of clinical truth. JAMA. 1978;239:960-1. Editorial. Two editorials explaining the need for medical ethics and the form its teaching should take. CrossrefMedlineGoogle Scholar11. CLOUSER K. Medical ethics: some uses, abuses and limitations. N Engl J Med. 1975;293:384-7. CrossrefMedlineGoogle Scholar12. CLOUSER K. What is medical ethics? Ann Intern Med. 1974;80:657-60. Two companion articles describe the nature and function of medical ethics: The first explains that medical ethics is the effort to understand how ordinary moral principles apply ▸From the University of California School of Medicine, San Francisco, California; the Stanford University School of Medicine, Stanford, California, and the University of Oregon Health Sciences Center and Veterans Administration Hospital, Portland, Oregon. to the complexities of medicine; the second states that medical ethics is not a reform movement but an attempt to structure the disputed issues by detailing and drawing the implications of the relevant principles, analyzing concepts, and gathering necessary factual information for decisions. LinkGoogle Scholar13. SIEGLER M. A legacy of Osler: teaching clinical ethics at the bedside. JAMA. 1978;239:951-6. Medical ethics, like medicine, should be taught at the bedside, using actual cases, by teams of physicians and ethicists: This heightens personal accountability and shows the relation between judgments of technical competence and ethical decisions. CrossrefMedlineGoogle Scholar14. SIEGLER M. Clinical ethics and clinical medicine. Arch Intern Med. 1979;139:914-5. This editorial accompanying five essays on ethical dilemmas in the management of respiratory failure stresses the inseparability of medical ethics and clinical medicine. CrossrefMedlineGoogle Scholar15. CLOUSER K. "The sanctity of live": an analysis of a concept. Ann Intern Med. 1973;78:119-25. The phrase "sanctity of life," often central to ethical discussions, is shown to be muddled and inconclusive; whatever value it has is better expressed in a moral rule such as "do not take human life." This rule is explained and its applicability analyzed. LinkGoogle Scholar16. JONSEN A. Do no harm. Ann Intern Med. 1978;88:827-32. This ancient maxim of medical ethics, still relevant to modern medicine, is shown to have four distinct but related uses: to express the moral ideal of medicine, to impose the obligation of due care, and to require both a risk-benefit ratio and a detriment-benefit equation in clinical judgments. A discussion of euthanasia exemplifies these four uses. LinkGoogle Scholar17. BARBER B. Compassion in medicine: toward new definitions and new institutions. N Engl J Med. 1976;295:939-43. Compassion, long considered a primary virtue, is reflected differently in two patterns of the patient-physician relationship: the tradional relationship based on the paternalistic authority and the emerging one based on mutuality and patient autonomy. These two patterns have major implications for medical care. CrossrefMedlineGoogle Scholar18. SCHOOLMAN H. The role of the physician as a patient advocate. N Eng J Med. 1977;296:103-5. The physician's primary concern should be the patient's welfare from the patient's perspective. Thus, as a decision maker in situations of uncertainty, the physician should be an advocate for the patient rather than the advocate of a particular therapy. CrossrefMedlineGoogle Scholar19. VEATCH R. Death, Dying and the Biological Revolution: Our Last Quest for Responsibility. New Haven: Yale University Press; 1976. This book treats the ethical issues surrounding dying and the care of the dying in a judicious and comprehensive way; it is, for the most part, a good summary statement of current thinking on these problems. Google Scholar20. BEAUCHAMPPERLIN TS, eds. Ethical Issues in Death and Dying. Englewood Cliffs, New Jersey: Prentice-Hall, Inc.; 1978. Google Scholar21. WEIR R, ed. Ethical Issues in Death and Dying. New York: Columbia University Press; 1977. CrossrefGoogle Scholar22. HORANMALL DD, eds. Death, Dying and Euthanasia. Washington, D.C: University Publishers of America; 1977. Google Scholar23. BEHNKEBOK JS, eds. The Dilemmas of Euthanasia. Garden City, New York: Anchor/Doubleday; 1975. Four anthologies containing philosophical, legal, theological, and medical articles on problems such as active and passive euthanasia, suicide, and care of the dying. Reference 23 was first published as a special issue of Bioscience. 1973,23:459-78. Google Scholar24. MCCORMICK R. To save or let die: the dilemmas of modern medicine. JAMA. 1974;229:172-6. Although directly addressing the problem of whether to treat defective newborns, the author states clearly an important traditional way of distinguishing between ordinary and extraordinary treatment and reinterprets it in terms of quality of life. CrossrefMedlineGoogle Scholar25. RABKINGILLERMANRICE MGN. Orders not to resuscitate. N Engl J Med. 1976;295:364-6. CrossrefMedlineGoogle Scholar26. Optimum care for hopelessly ill patients. N Engl J Med. 1976;295:362-4. Both articles deal with criteria and procedures for determining the most appropriate management of terminally ill patients, in particular, the decision not to resuscitate. CrossrefMedlineGoogle Scholar27. RACHELS J. Active and passive euthanasia. N Engl J Med. 1975;292:78-80. A philosopher's argument that the distinction between active and passive euthanasia, supposedly a crucial moral distinction, is unsound, principally because the distinction on which it rests, killing rather than allowing to die, is not ethically significant. CrossrefMedlineGoogle Scholar28. CLOUSER K. Allowing or causing: another look. Ann Intern Med. 1977;87:622-4. The distinction between allowing to die and killing is shown to be ethically relevant for decisions about termination of therapy because it rests on the presence or absence of the duty to treat, not on a distinction between physical acts. LinkGoogle Scholar29. JONSEN A. Dying right in California. Clin Res. 1978;26:55-60. The physician's duty to treat is limited by the wishes of patients and the usefulness of treatment: Both elements are involved in clinical judgments about termination of therapy, as illustrated in California's "Natural Death" legislation. MedlineGoogle Scholar30. VANDERPOOL H. The ethics of terminal care. JAMA. 1978;239:850-2. The ethics of care for the terminally ill should not be based on the unclear and unsuitable concept of "death with dignity," but on the concept of human worth, which has four implications for clinical care: respect for the autonomy of the dying patient, the importance of community with and for the dying, concern for the body and its needs, and personal convictions about ultimate destiny. CrossrefMedlineGoogle Scholar31. . Guidelines concerning assistance to the dying. Republished in Hastings Cent Rep. June 1977;7:30-1. Available from the Institute of Society, Ethics and the Life Sciences, 360 Broadway, Hastings-on-Hudson, NY 10706. The probable wishes of the incompetent dying patient should determine the physician's decisions about omitting or discontinuing therapy. Excellent statement of physicians' ethical responsibility in care for the dying. Google Scholar32. A definition of irreversible coma: report of the Ad Hoc Committee of the Harvard Medical School. JAMA. 1968;205:337-40. Prompted by advances in resuscitation and transplantation, a special committee rethought the traditional definition of death (loss of vital signs) and proposed an alternative, brain death, based on operational criteria of "irreversible coma." A landmark deliberation. CrossrefMedlineGoogle Scholar33. . Refinements in criteria for the determination of death: an appraisal. JAMA. 1972;221:48-53. A concise description of characteristics of good criteria for a definition of death and an analysis of how the Harvard Committee's criteria measure up to these criteria. Controversy about criteria for determining death. CrossrefMedlineGoogle Scholar34. VIETHFINETENDERVEATCHKEIMANKALKINES FJMRMG. Brain death: I. A status of medical and ethical considerations: II. A status of legal considerations. JAMA. 1977;238:1651-5, 1744-8. CrossrefMedlineGoogle Scholar35. BLACK M. Brain Death: I, II. N Engl J Med. 1978;299:338-344, 393-401. Both articles review the criteria for determining brain death, the clinical studies supporting these criteria, and the use of the criteria within the context of ethical and religious beliefs as well as legal grounding. CrossrefMedlineGoogle Scholar36. BOK S. Personal directions for care at the end of life. N Engl J Med. 1976;295:367-9. An analysis of some current forms of the living will, whereby a patient gives directions to the personal physician regarding terminal illness; the author explains the rationale for such documents and proposes a clear formulation. CrossrefMedlineGoogle Scholar37. IMBUSZAWACKI SB. Autonomy for burned patients when survival is unprecedented. N Engl J Med. 1977;297:308-11. CrossrefMedlineGoogle Scholar38. CASSELL J. Autonomy and ethics in action. N Engl J Med. 1977;297:333-4. The first article reports the practice of a major burn unit which, in affirmation of the autonomy of patients, offers to lucid patients with burns so severe that survival is unprecedented a choice between full therapeutic regimen and supportive care. The second article is an editorial noting the import of respecting patient autonomy in clinical decisions. CrossrefMedlineGoogle Scholar39. CRYERKISSANE PJ, eds. Clinicosociologic conference: decisions regarding the provision or withholding of therapy. Am J Med. 1976;61:915-23. Transcript of conference showing the complexity of such decisions and the difficulties physicians face. CrossrefMedlineGoogle Scholar40. SPENCER S. "Code" or "no code": a nonlegal opinion. N Engl J Med. 1979;300:138-9. Patients' interests, not family wishes, justify decisions about resuscitation; physicians have primary responsibility. CrossrefMedlineGoogle Scholar41. EPSTEIN F. Responsibility of the physician in the preservation of life. Arch Intern Med. 1979;139:919-20. Eloquent reminder that withholding efficacious treatment from seriously ill patients may benefit the family and physician more than the patient. CrossrefMedlineGoogle Scholar42. CASSEM N. Being honest when technology fails. Harvard Med School Alumni Bull. 1978;53:23-7. The experience of the optimal care committee at the Massachusetts General Hospital. Emphasizes the limitations of technology, the fallibility of medical judgment, and the need for honest communication. Google Scholar43. RELMAN A. The Saikewicz decision: judges as physicians. N Engl J Med. 1978;298:508-9. Physicians and families, not the courts, are the proper decision-makers on withholding treatment from critically ill incompetent patients. CrossrefMedlineGoogle Scholar44. BARRON C. Medical paternalism and the rule of law: a reply to Dr. Relman. Am J Law Med. 1979;4:337-65. A lawyer responds to the preceding article, arguing that the judiciary is best suited to make such decisions because of the safeguards of the legal process. MedlineGoogle Scholar45. GLANTZSWAZEY LJ. Decisions not to treat: the Saikewicz case and its aftermath. Forum Med. 1979;2:22-32. This overview of the Saikewicz and Quinlan cases discusses the criteria for decision, quality of life, criminal and civil liability, and orders not to resuscitate. MedlineGoogle Scholar46. ANNAS G. Reconciling Quinlan and Saikewicz: decision making for the terminally ill incompetent. 1979;4:367-96. Physicians should make medical judgments, but the courts should decide on social questions. The advice given to physicians by lawyers after the Saikewicz case was often incorrect. Google Scholar47. JACKSONYOUNGER DS. Patient autonomy and "death with dignity": some clinical caveats. N Engl J Med. 1979;301:404-8. Six cases in which patient or family wishes to decline treatment in an intensive care unit actually reflected ambivalence, fear, misunderstanding, and underlying psychological problems. CrossrefMedlineGoogle Scholar48. CRANE D. Decisions to treat critically ill patients: a comparison of social versus medical considerations. Milbank Mem Fund Q. Winter 1975;53:1-33. Sociological study of physicians' attitudes towards critical illness, death, technology, social and cultural attributes of patients, and how these variables affect decision-making in different insititutional settings. Physicians are shown to rank patients for intensive therapy in terms of salvageability with some physical damage, salvageability with mental damage, and unsalvageable, in descending order. CrossrefMedlineGoogle Scholar49. ANNAS G. Informed consent. Annu Rev Med. 1978;29:9-14. Concise, complete, lucid overview. CrossrefMedlineGoogle Scholar50. LEBACQZLEVINE KR. Respect for persons and informed consent to participate in research. Clin Res. 1977;25:101-7. This comprehensive review analyzes the concept of autonomy or respect for persons and the conflicts between autonomy and protection of patients. MedlineGoogle Scholar51. LOFTUSFRIES EJ. Informed consent may be hazardous to health. Science. 1979;204:11. Editorial. Explicit suggestion of adverse effects may cause them to occur by a placebo effect. The discussion is applicable to patient care as well as research. CrossrefMedlineGoogle Scholar52. MORROWGOOTNICKSCHMALE GJA. A simple technique for increasing cancer patients' knowledge of informed consent to treatment. Cancer. 1978;42:793-9. In a randomly controlled prospective study, oncology patients who took consent forms home overnight showed greater short-term understanding of treatment and alternatives. CrossrefMedlineGoogle Scholar53. ALFIDI R. Controversy, alternatives, and the decisions in complying with the legal doctrine of informed consent. Radiology. 1975;114:231-4. CrossrefMedlineGoogle Scholar54. ALFIDI R. Informed consent: a study of patient reaction. JAMA. 1971;216:1325-9. Studies on how much information patients about to undergo radiology procedures wish to have: The majority welcomed information, and only a very small number refused procedures on the basis of information. CrossrefMedlineGoogle Scholar55. ROTHMEISELLIDZ LAC. Tests of competency to consent to treatment. Am J Psychiatry. 1977;134:279-83. Various tests of competency are commonly used: evidence of choice, reasonable decision, rational reasons, ability to understand, and actual understanding. CrossrefMedlineGoogle Scholar56. WINKLER D. Persuasion and coercion for health: ethical issues in government efforts to change life-styles. Milbank Mem Fund Q. 1978;56:303-38. A thoughtful exposition of three possible goals for improved health behavior: health valued for its own sake, fair distribution of burdens caused by illness, and improvement of the general welfare—and a brief description of means that government could use to stimulate these improvements; the implications of these means for personal freedom and autonomy. CrossrefMedlineGoogle Scholar57. MEENAN R. Improving the public's health—some further reflections. N Engl J Med. 1976;294:45-6. Despite the new enthusiasm for life-style reform to improve health, recommendations for life-style changes should be based on sound casual relationships; there is danger that physicians and society dictate these changes to people with little evidence of efficacy. CrossrefMedlineGoogle Scholar58. GAYLIN W. On the borders of persuasion: a psychoanalytic look at coercion. Psychiatry. February 1974;37:1-9. Coercion, which may be emotional as well as physical, has been traditionally respectable in medicine when the purpose of the coercion is the patient's best interests. Physicians have great manipulative power in defining sickness and health and acceptable limits of behavior; sometimes neither physician nor patient is aware of the physician's coercion, and it may even masquerade as the patient's free consent. CrossrefMedlineGoogle Scholar59. WALTERS L. Ethical aspects of medical confidentiality. Clin Comput. 1974;4 (1):9-20. Two arguments justify the principle of confidentiality for medical information: (1) The promise of confidentiality facilitates the patient's full disclosure of causes and symptoms to the physician; and (2) by the right to privacy, each person can determine the extent that his thoughts are communicated to others. Confidentiality can be overridden only to protect the patient's life (as with threatened suicide) or others' lives (as with reporting communicable diseases). MedlineGoogle Scholar60. BRITTON A. Rights to privacy in medical records. Leg Med. July-August 1975;3(7):30-7. The conflict between the patient's right to privacy and the disclosure of medical information for certain public purposes. Four conditions establish a privilege against evidentiary disclosure of confidential communications: (1) The communication has to originate under a promise of nondisclosure; (2) confidentiality must be essential to the ongoing relationship of the parties; (3) the community must want to support the relationship; and (4) the injury to the relationship by disclosure outweighs the risk of improper resolution of the case by nondisclosure. Physician-patient communications meet these conditions and should legally have the privilege of confidentiality. Google Scholar61. ZENOFF E. Confidential and privileged communications. JAMA. 1962;182:656-62. A concise review of privileged communications' legal history, criticism of claims for physician-patient privilege, and the relevant differences between physician-patient communications and priest-penitent or psychotherapist-patient communications. MedlineGoogle Scholar62. SIDEL V. Confidential information and the physician. N Engl J Med. 1961;264:1133-7. Despite certain laws requiring physicians to disclose information about patients, the tradition of medical ethics supports the position that a physician should keep strict confidences unless he can prevent a crime or the spread of communicable disease by their disclosure. CrossrefGoogle Scholar63. CURRANSTEARNSKAPLAN WBH. Privacy, confidentiality and other legal considerations in the establishment of a centralized health-data system. N Engl J Med. 1969; 281:241-8. A review of key legal concepts about confidentiality and privacy; the proper use of hospital records, public welfare records, and other personal records; and specific recommendations for safeguarding records' confidentiality in centralized data banks. CrossrefMedlineGoogle Scholar64. FIORE N. Fighting cancer—one patient's perspective. N Engl J Med. 1979;300:284-9. Physicians should include patients in decision-making because a sense of autonomy and control can have positive effects on quality of life and even recovery. Patients in research protocols should not be made to feel an obligation to continue for the sake of the research. CrossrefMedlineGoogle Scholar65. MCNEILWEICHSELBAUMPAUKER BRS. Fallacy of the five-year survival in lung cancer. N Engl J Med. 1978;299:1397-401. Medical decision-making tends to emphasize physicians' own values in risk-benefit consideration, not those of the patients. Of 19 patients with operable lung cancer, most would choose radiotherapy rather than surgery, even though 5-year survival rates are better with surgery. A quantitative method of measuring attitudes towards risk is presented. CrossrefMedlineGoogle Scholar66. SHENKINWARNER BD. Giving the patient his medical record: a proposal to improve the system. N Engl J Med. 1973;289:688-92. The authors review possible advantages and answer some objections to a policy that patients automatically be issued their complete medical records. CrossrefMedlineGoogle Scholar67. FOSTCOHEN NS. Ethical issues regarding case reports: to publish or perish the thought. Clin Res. 1976;24:269-73. Possible courses of action for authors, whose data may be scientifically important but sensitive and identifying of subjects, and for editors who review these papers. Recommends formal group reviews of data for dissemination and publication (as well as the established procedures for review of data collection methods) to protect patients' privacy. MedlineGoogle Scholar68. ARTISSLEVINE KA. Doctor-patient relation in severe illness: a seminar for oncology fellows. N Engl J Med. 1973;288:1210-4. A group of oncology fellows attempt to come to terms with the philosophical problems in caring for cancer patients. The problems are located in the relationship rather than attributed to either physicians or patients. Philosophical concepts are used in a concrete way relevant to all clinicians regardless of specialty. CrossrefMedlineGoogle Scholar69. GROVES J. Taking care of the hateful patient. N Engl J Med. 1978;298:883-7. Hatred, aversion, and malice towards certain patients is candidly discussed. Identification and management of problem patients is emphasized more than ethical analysis. CrossrefMedlineGoogle Scholar70. DUNPHY J. Annual discourse—on caring for the patient with cancer. N Engl J Med. 1976;295:313-9. Personal reflections of an eminent surgeon covering ethical issues in critical and terminal disease, including disclosure of diagnosis and prognosis, obligations of caregivers, termination of artificial life support, and euthanasia. CrossrefMedlineGoogle Scholar71. VILARDELL F, ed. Ethical problems in the management of gastroenterological patients. Scand J Gastroenterol [Suppl]. 1977;12:1-60. Entire issue devoted to description of risk-benefit of procedures in diagnosis and therapy, as well as in research. Google Scholar72. MARKSSACHER RE. Undertreatment of medical inpatients with narcotic analgesis. Ann Intern Med. 1973;78:173-81. Inadequate knowledge of the pharmacology of narcotics and exaggerated concern for possible addiction cause undertreatment of medical pain syndromes, leading to unnecessary suffering among hospitalized patients. LinkGoogle Scholar73. HERBERT V. Medical, legal and ethical considerations in the use of drugs having undesirable side effects. Am J Clin Nutr. 1975;28:555-60. Legal precedents and constraints uphold ethical principles in problems of drug toxicity. Both medical and ethical conjecture are essential to optimal therapeutics. CrossrefMedlineGoogle Scholar74. TWYCROSS R. The use of narcotic analgesis in terminal illness. J Med Ethics. 1977;3:10-7. Available from the Society for the Study of Medical Ethics, Tavistock House East, Tavistock Square, London WC1H 9LG, England. The scientific and compassionate use of narcotics for pain can greatly improve quality of life in terminal illness. Effective dose varies widely, tolerance and dependence are not a problem, oral administration is feasible and effective. Human comforting, as well as physical and occupational therapy, reduces drug requirements. Google Scholar75. BOK S. The ethics of giving placebos. Sci Am. 1974; 2317:17-23. Widespread use of placebos and placebo effect has been justified by beneficial results in patient care and by necessity in therapeutic research. Harmful aspects of this practice include side effects of unnecessary drugs, excessive reliance on medication, and, most significant, the danger of eroding trust between patient and physician. CrossrefGoogle Scholar76. DAVIESROBINSONPARKES EJC. The patient's right to know the truth. Proc R Soc Med. 1973;66:533-8. Legal aspects are amplified by short and eloquent discussions of religious, ethical, and psychosocial arguments in favor of informing patients of critical risks or terminal diagnosis. MedlineGoogle Scholar77. NOVACKPLUMERSMITHOCHITILLMORROWBENNETT DRRHGJ. Changes in physicians' attitudes toward telling the cancer patient. JAMA. 1979;241:897-900. A 1961 study by Oken showed that 90% of physicians would not tell their patients of a cancer diagnosis. The same questionnaire in 1979 shows that 97% indicate a preference for disclosure. In both studies, almost all patients expressed a desire to know their diagnosis. Personal and emotional factors played the greatest role in forming and maintaining physicians' attitudes. CrossrefMedlineGoogle Scholar78. LEVINELEBACQZ RK. Ethical considerations in clinical trials. Clin Pharmacol Ther. 1979;25:728-46. Ethical principles that regulate clinical research can be applied to specific ethical dilemmas in clinical trials. Pros and cons of randomized clinical trials are debated in terms of ethics and scientific rigor. This entire issue is devoted to methods and ethics in clinical trials. CrossrefGoogle Scholar79. FEINSTEIN A. Medical ethics and the architecture of clinical research. Clin Pharmacol Ther. 1974;15:316-34. Ethical constraints may limit research methods so that valuable information for patient care is harder to obtain, but individual rights are preserved. CrossrefMedlineGoogle Scholar80. WALTERS L. Some ethical issues in research involving human subjects. Perspect Biol Med. 1977;20:193-211. Major issues in ethics of research are succinctly analyzed: risk-benefit, selection of subjects, informed consent, social control, research design, compensation of injured subjects, and basic moral justification for research. CrossrefMedlineGoogle Scholar81. SHAWCHALMERS LT. Ethics in cooperative clinical trials. Ann NY Acad Sci. 1970;169:487-95. Statement of principles required for ethical justification of a randomized clinical trial. CrossrefMedlineGoogle Scholar82. FRIED C. Medical Experimentation: Personal Integrity and Social Policy. New York: American-Elsevier Publishing Co.; 1974. Thorough discussion of the law and ethics of human experimentation, including considerations of the concepts of personal care, individual rights and duties, societal claims and obligations. Google Scholar83. SPIRO H. Constraint and consent—on being a patient and a subject. N Engl J Med. 1975;293:1134-5. Ethical conflicts in therapeutic research include problems of freedom of consent, disregard for the personal aspects of care for seriously ill patients, and different priorities of allegiance to society and to individuals. Caregiver and researcher should be clearly separate roles and perhaps separate persons. CrossrefMedlineGoogle Scholar84. BARBER B. The ethics of experimentation with human subjects. Sci Am. 1976;234:25-31. A single, large multicenter study finds inadequate concern for patients' rights among researchers. Major related studies are reviewed and lend support. Lack of ethics teaching in medical schools and personal career ambitions are cited as contributing factors. CrossrefMedlineGoogle Scholar85. BEECHER H. Ethics and clincial research. N Engl J Med. 1966;274:1354-60. This classic report, which cites unethical practices in research, was a strong stimulus to the development of the field of bioethics. CrossrefMedlineGoogle Scholar86. AXELSENWIGGINS DR. An application of moral guidelines in human clinical trials to a study of a benzodiazepine compound as a hypnotic agent among the elderly. Clin Res. 1977;25:1-7. An apparently innocuous research proposal shows several significant ethical problems. A good model of strict ethical analysis. MedlineGoogle Scholar87. DEBAKEY L. Ethically questionable data: publish or reject? Clin Res. 1974;22:113-21. Editorial. Should reputable journals publish reports of research conducted under ethically questionable circumstances? Both sides of the question are analyzed, and stricter editorial review is encouraged. MedlineGoogle Scholar88. VEATCHBRANSON RR. Ethics and Health Policy. Cambridge, Massachusetts; Ballinger; 1976. Essays showing how the problem of allocation of health care can be analyzed in terms of ethical theory. Google Scholar89. FUCHS V. Who Shall Live? New York: Basic Books, Inc., 1974. An economist writing for the noneconomist, Fuchs examines American health-care delivery's problems of high cost, unequal distribution, and inadequate results. This well-written, substantial little book asks the question, how should Americans use their health care resources equitably? Google Scholar90. . The ailing health care system. West J Med. 1978;128:512-26. An overview of the implications of rising health-care costs including case presentations; data on high-cost medical care; a proposal for improving the clinical decision-making process to cope with high costs of care; and prospects for future containment of costs by consumers, physicians, hospitals, and government. Considers ethical issues: Should cost be a consideration in clinical decisions; should health benefits be distributed by need or ability to pay; who should have authority over resources? MedlineGoogle Scholar91. ROY W. An agenda for physicians and legislators, 1976. N Engl J Med. 1976;295:589-96. Medical resources are limited, and some rationing will be needed; rationing plans are reviewed, ranging from practitioners' dispensing care based on their own cost-benefit assessments, to professional standards review organizations, to governmental regulation. CrossrefMedlineGoogle Scholar92. HIATT H. Protecting the medical commons: who is responsible? N Engl J Med. 1975;293:235-41. Medical-care resources are "clearly approaching depletion," a call for national priorities of health care. Physicians cannot be asked, however, to make clinical decisions in terms of national policy because of their obligation to care for patients. CrossrefMedlineGoogle Scholar93. SCHWARTZJOSKOW WP. Medical efficacy versus economic efficiency: a conflict of values. N Engl J Med. 1978;299:1462-4. Wastefulness accounts for a small part of health-care costs; the important question is how often too little medical benefit is bought at too much cost. Medical efficacy may conflict directly with economic efficiency in health care. CrossrefMedlineGoogle Scholar94. FEIN R. But, on the other hand: high blood pressure, economics and equity. N Engl J Med. 1977;296:751-3. Editorial. Values always underlie cost-benefit and cost-effectiveness analysis. Proposals for health-care efficiency, however, do not address the problem of equity of access—the most important unsolved problem for health-care delivery systems. CrossrefMedlineGoogle Scholar95. FRIED C. Rights and health care—beyond equity and efficiency. N Engl J Med. 1975;293:241-5. Right to health care means access to one's fair share of health resources and assurance of humane, honest care. Such a right may conflict, however, with principles of economic efficiency and distributive equity. CrossrefMedlineGoogle Scholar96. CULLEN D. Results and costs of intensive care. Anesthesiology. 1977;47:203-16. Patients in an intensive-care unit in one hospital incurred an average hospitalization bill of $14 000 by death or discharge, and only 27% were alive 1 year later. Does intensive care justify its costs? CrossrefMedlineGoogle Scholar97. TELFER E. Justice, welfare and health care. J Med Ethics. 1976;2:107-11. A criticism of four different systems for distributing and financing health care: laissez faire, liberal humanitarian, liberal socialist, and pure socialist, the four considered on grounds of ethical theories of justice. Particularly relevant to the debate over national health insurance. MedlineGoogle Scholar This content is PDF only. To continue reading please click on the PDF icon. Author, Article, and Disclosure InformationAffiliations: San Francisco and Stanford, California; and Portland, Oregon PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byAmerican College of Physicians Ethics Manual Part II: Research, Other Ethical Issues. Recommended Reading.Ethical Dilemmas and the ClinicianBERNARD LO, M.D., ALBERT R. JONSEN, PH.D 1 January 1980Volume 92, Issue 1Page: 136-141KeywordsMedical ethics Issue Published: 1 January 1980 Copyright & Permissions©1980 American College of PhysiciansPDF downloadLoading ...