Extract We are entering an era where medicine is becoming more like engineering. The distinction between “treatment” and “enhancement” blurs as we are ever better at tinkering with the body. . .
Medical scientists will be able to modify and control an ever-expanding range of human bodily functions, from drugs that slow down aging to drugs that alter basic aspects of mood, anxiety, and cognition. Someday soon, the conflict between a physician’s idea of how people ought to live and how those people want to live will occur in fields far removed from reproductive technology. . .
Abstract The film “Who Should Survive?: One of the Choices on Our Conscience” contains a dramatization of the death of an infant with Down syndrome as the result of the parents’ decision not to have a congenital intestinal obstruction surgically corrected. The dramatization was based on two similar cases at The Johns Hopkins Hospital and was financed by the Joseph P. Kennedy, Jr., Foundation. When “Who Should Survive?” was exhibited in 1971, the public reaction was generally critical of the parents’ decision and the physicians’ inaction. Although technological developments in medicine were a necessary condition for the production of this film and its unanticipated reception, they were not a sufficient condition. The proximate cause was a changed understanding of the capabilities of individuals with Down syndrome. Part of the impetus for this change was data showing the adverse effects of institutionalization on normal children.
Abstract This essay examines (1) the underlying philosophical considerations when patients or decision makers request “inappropriate treatment”; (2) questions to consider in determining if the treatment sought would be ineffective, or, in the words of Weijer et al., effective toward a controversial end; and (3) practical ways to resolve such conflicts.
Suziedelis A. Requests for Inappropriate Treatment: Can A Doctors “Just Say ‘No'”? Health Care Ethics USA. 2005;13(1):E2
Abstract A competent person can avoid the onset of dementia by refusing life-sustaining medical care and by voluntarily stopping eating and drinking, bringing life to an end well before any health crisis. A competent person can also try to limit the duration of dementia by drafting an advance directive that sets bounds on the life-sustaining care, including artificial nutrition and hydration, that medical caregivers can provide when the person no longer has the capacity to make her own medical decisions. But between these two strategies there can lie a significant gap. A person could live with moderate to severe dementia for a considerable time, no longer able to voluntarily stop eating and drinking yet also not yet requiring the life-sustaining care forbidden by advance directive. This gap has been much discussed in recent years in the Hastings Center Report. Several years ago (in the May-June 2014 issue), Paul Menzel and M. Colette Chandler-Cramer argued for what they described as a moderate correction to the dominant view that food and water should always be offered to a patient with dementia if the patient expresses a desire to eat and drink. The problem is taken up again by the legal scholar Norman L. Cantor in this issue (July-August 2018), and Cantor, too, tries to find a moderate alternative.
Extract A series of attention-grabbing lawsuits and a crop of new legislation have spotlighted a long-gathering movement to vastly expand the scope of policies allowing health care providers, institutions and payers to refuse to participate in sexual and reproductive health services by claiming a moral or religious objection. In some cases, these radical new policies are intentionally designed to undermine, if not actually eliminate, the ability of governments at all levels, and even private businesses, to balance providers’ “conscience” rights with the ability of patients to exercise their own conscience and gain access to health care services that they want and need.
Abstract Bioethics has focused on the areas of individual ethical choices — patient care — or public policy and law. There are however, important arenas for ethical choices that have been overlooked. Health care is populated with intermediate arenas such as hospitals, nursing homes, hospices, and health care systems. This essay argues that bioethics needs to develop a language and concepts for institutional ethics. A first step in this direction is to think about institutional conscience.
Abstract Managed care organizations can produce conflicts of obligation and conflicts of interest that may lead to problems of conscience for health care professionals. This paper provides a basis for understanding the notions of conscience and conscientious objection and offers a framework for clinicians to stake out positions grounded in personal conscience as a way for them to respond to unacceptable pressures from managers to limit services.
JE Steinauer, T DePineres, AM Robert, J Westfall, P Darney
Family Planning Perspectives
Abstract The majority of residents responding to a 1995 survey of program directors and chief residents at 244 family medicine residency programs in the United States reported they had no clinical experience in cervical cap fitting, diaphragm fitting or IUD insertion and removal. For all family planning methods except oral contraceptives, no more than 24% of residents had experience with 10 or more patients. Although 29% of programs included first-trimester abortion training as either optional or routine, only 15% of chief residents had clinical experience providing first-trimester abortions. Five percent of residents stated they certainly or probably would provide abortions, while 65% of residents stated they certainly would not provide abortions. A majority (65%) of residents agreed that first-trimester abortion training should be optional within family practice residency programs. Residents were more likely to agree with inclusion of optional abortion training and with the appropriateness of providing abortions in family practice if their program offered the training.
Abstract PIP: This article is a reflection on the Fourth World Conference on Women in Beijing in September 1995, including its preparatory meetings. Delegates from 187 nations negotiated and decided on the disputed passages of the draft Platform of Action, which comprised 40% of the 150 page document. The atmosphere prior and during the conference was not peaceful. The UN and China disputed over the location of the nongovernmental organizations’ (NGO) forum that took place at the same time of the conference. The US and Chinese governments squabbled about China’s detention of a Chinese-American human rights activist. The US First Lady attended the conference and the NGO forum, promoting human rights. Most delegates had decided that this conference would not be a retreat from the Cairo conference. In comparison to Cairo, the Vatican delegation had toned down its opposition. US based antiabortion groups and conservative women’s groups arrived in greater numbers in Beijing than in Cairo, in hopes to reverse actions taken in Cairo. They had few victories. A contentious issue was parental rights and responsibilities, specifically adolescents’ access to confidential health services. Compromise wording was worked out in two paragraphs. All other references to parental rights were deleted or there was a reference to the compromise wording. The Beijing platform was the first universal document recognizing the right of a woman to say no to sexual intercourse. The references in the Beijing document recognizing sexual rights as human rights were a major accomplishment. Debates over the issue of abortion took place: the proposed conscience clause and a call for the review of laws containing punitive measures against women who have had an illegal abortion. The vocal delegates from developing countries are silencing the accusation that radical Western women are thrusting women’s rights on the rest of the world.
Extract The ethical principles of care have to balance patient autonomy or control with the justice owed to society as a whole. Our choices do not take place in a purely individual setting and the change in society’s attitude when a hastened death is available is illustrated by the changes that are taking place in the Netherlands.
