Issues In Medical Ethics Research Articles

ON ASKING THE RIGHT QUESTIONS: PERSONAL DEATH VS. BRAIN DEATH IN JAPAN

This article addresses methodological concerns encountered during the author's recent fellowship tenure at the University of Tokyo's School for International Health. His research addressed matters relating to Japanese views of personal death within the context of the relationship between self and body. He was also interested in learning more about the extent to which these same views influence issues in medical ethics, particularly the ongoing debate over brain death and heart transplantation, which, until June 1997, was legally prohibited. One critical component in methodology involved interviews and discussions with prominent scholars representing various disciplines. The key feature in these meetings centered around specific core questions. The author describes how these questions underwent significant modifications, and discusses how these methodological adjustments in effect reveal notions that are substantive and relevant to the research design pertaining to Japanese views of death, self, and embodiment.

An assessment of orthopaedic surgeons' knowledge of medical ethics.

We developed a survey instrument to evaluate knowledge of ethical issues among orthopaedic surgeons and to assess their ability to handle ethical dilemmas. The twenty-six-item survey evaluates seven areas of medical practice: confidentiality, informed consent, truth-telling, the physician-patient relationship, economic aspects of care, end-of-life decision-making, and the approach to an incompetent colleague. It was administered to 117 attending orthopaedic surgeons and residents in two orthopaedic surgery training programs. One hundred and two orthopaedic surgeons (87 per cent) completed the survey. Overall, they correctly answered a mean of nineteen (73 per cent) of the twenty-six questions. The respondents appropriately handled questions involving economic aspects, truth-telling, confidentiality, and an incompetent colleague. However, there was poorer understanding of proper ethical conduct with regard to informed consent (58 per cent of the responses were correct), the physician-patient relationship (72 per cent of the responses were correct), and end-of-life decision-making (78 per cent of the responses were correct). No significant differences were found, with the numbers available, in overall performance according to site, attending compared with resident status, age, gender, or whether the physician had had training in ethics. Economic, social, and professional forces have increased the medical ethical issues facing orthopaedic surgeons. Medical ethics now must be taught in training programs in orthopaedic surgery. Our survey of two orthopaedic surgery training programs demonstrated that orthopaedic surgeons approach most medical ethical problems appropriately. However, improvement is needed in selected areas.

Flynn, E.P. 1997, Issues in Medical Ethics

Flynn, E.P. 1997, Issues in Medical Ethics

Medical ethics research between theory and practice.

The main object of criticism of present-day medical ethics is the standard view of the relationship between theory and practice. Medical ethics is more than the application of moral theories and principles, and health care is more than the domain of application of moral theories. Moral theories and principles are necessarily abstract, and therefore fail to take account of the sometimes idiosyncratic reality of clinical work and the actual experiences of practitioners. Suggestions to remedy the illness of contemporary medical ethics focus on re-establishing the connection between the internal and external morality of medicine. This article discusses the question how to develop a theoretical perspective on medical ethical issues that connects philosophical reflection with the everyday realities of medical practice. Four steps in a comprehensive approach of medical ethics research are distinguished: (1) examine health care contexts in order to obtain a better understanding of the internal morality of these practices; this requires empirical research; (2) analyze and interpret the external morality governing health care practices; sociological study of prevalent values, norms, and attitudes concerning medical-ethical issues is required; (3) creation of new theoretical perspectives on health care practices; Jensen's theory of healthcare practices will be useful here; (4) develop a new conception of bioethics that illuminates and clarifies the complex interaction between the internal and external morality of health care practices. Hermeneutical ethics can be helpful for integrating the experiences disclosed in the empirical ethical studies, as well as utilizing the insights gained from describing the value-contexts of health care practices. For a critical and normative perspective, hermeneutical ethics has to examine and explain the moral experiences uncovered, in order to understand what they tell us.

Issues in medical ethics

Issues in medical ethics

Arden Syntax: the emerging standard language for representing medical knowledge in computer systems.

The Arden Syntax for Medical Logic Modules standard language for knowledge-based computer systems is described. Knowledge systems can use computerized patient data in decision-making. Although they have the potential to reduce adverse drug events and infection rates, improve drug dosing, and decrease the cost of care, knowledge systems have not yet reached the average patient. Arden Syntax for Medical Logic Modules is the standard language for defining clinical decision rules that drive alerts, reminders, clinical guidelines, and data interpretations. Each medical logic module (MLM) in an Arden Syntax knowledge base is designed to make one type of decision. MLMs usually represent either rules that can be encoded, such as generating a warning that the potassium concentration is decreasing in a patient taking digoxin, or complex decision trees for individual patient care plans and clinical protocols. An MLM contains maintenance slots (title, file name, version, originating institution, author, date, specialist, validation information), library slots (stating the MLM's purpose and providing keywords for searching), and knowledge slots (containing the "essence" of the MLM). Arden Syntax is receiving growing support from the medical and information systems communities as the standard language for medical knowledge systems, but legal, ethical, regulatory, and ownership issues remain. If pharmacy is to grow and prosper as a knowledge profession, it should adopt an accepted standard language for representing active, applied knowledge in computer systems.

Issues of Medical Ethics in the Catechism of the Catholic Church

Christ's preferential love for the sick has not ceased through the centuries to draw the very special attention of Christians toward those who suffer in body and soul It is the source of [their] tireless efforts to comfort them. (#1503)

Information and medical ethics: protecting patient privacy

As medical records become electronic, pieces of everyone's health history will reside in public and private computer repositories. The paper discusses issues of medical ethics, including the protection of patient privacy.

Cultural Psychiatry: Theoretical, Clinical, and Research Issues

As a discipline, cultural psychiatry has matured considerably in recent years and the ongoing quality of its theoretical, clinical, and research development holds great promise. The contemporary emphasis on culture as process permits a deeper analysis of the complexities of sociosomatics--the translation of meanings and social relations into bodily experience--and, thus, of the social course of illness. We also are learning a great deal more about cultural processes that affect therapy, including ethnopharmacologic and culturally valid family interventions that are directly relevant to patient care and mental health policy. And an important set of studies is examining the trauma experienced by refugees and immigrants. But at the same time many disquieting findings still point to the limited impact of cultural psychiatry on knowledge creation and clinical application in psychiatry. The failure of the cultural validation of DSM-IV is only the most dismaying. The persistent misdiagnosis of minority patients and the continued presence of racial bias in some treatment recommendations are also disheartening, as is the seeming contempt of many mainstream psychiatrists for culturally defined syndromes and folk healing systems. Widespread inattention to ethnic issues in medical ethics is another source of dismay. It is for these reasons that the culture of psychiatry itself becomes as important as the culture of patients as a topic for research and intervention. Most of the world still suffers from a terrible lack of basic mental health services, including life-saving medications and hospital beds. In the face of these limitations, and because of the increasing multicultural and pluralistic reality of contemporary life, the growing interpretive bridges linking indigenous systems of illness classification and healing to Western nosologies and therapeutic modalities become even more essential and the reluctance of mainstream clinicians to explore folk healing methods more incomprehensible. Psychiatry needs new ways of delivering culturally appropriate care to the disenfranchised and the destitute, for whom mainstream approaches are often too expensive, foreign, and centralized. As a profession, we also have much to learn from indigenous diagnosticians and therapists. Finally, psychosomatic, mind-brain, behavioral health, and psychopathologic investigations need to configure the social world in their paradigms of research if we are to understand better the sources and consequences of mental illness. Psychiatry can no more afford to be contextless than it can afford to be mindless or brainless.

Physician-Assisted Suicide: Family Issues

IntroductionThe publicity surrounding the activities of Dr. Jack Kevorkian since 1990 has brought to the forefront as a medical-ethical issue in Michigan. Proponents of assisted generally address the individual patient's right to be free of suffering and to exercise control over the circumstances of dying. Opponents commonly focus upon religious arguments against and mercy killing; the slippery slope of feared societal consequences; and violations of physician integrity should physicians become involved in deliberately causing death. As the debate is thus framed, it is easy to assume that the family has no role, or merely a peripheral one.In this paper I will address the various ways in which the family emerges as a focus of concern, upon a deeper or broader understanding of the issues raised by suicide. I will address these issues principally from the viewpoint of medical ethics, and secondarily from the perspective of a family physician; I make no pretense of being a family psychologist or family therapist.While I will show below that the family has hardly been absent from ethical discussions about suicide, the lack of clear focus upon the family dimensions of the topic may signal a more basic problem with medical ethics as it has emerged over the past quarter century in the U.S. James Lindemann Nelson (1992), among others, has criticized today's medical ethics for lacking a cogent conception of the role of the family. To put the matter in the simplest possible terms, much of modern medical ethics has been based upon the principle of respect for individual autonomy. This has led to the assumption that the family enters in either as a mere extension of individual autonomy (as when, for instance, a patient who was brought up as a Jehovah's Witness freely chooses to forego a blood transfusion), or else as a threat to autonomy (as when, for instance, a reluctant Jehovah's Witness refuses a transfusion, and the medical caregivers suspect that he would have accepted it but for undue pressure from family members). The possibility that an individual possesses and exercises autonomy only within the context of a set of social relationships, among which the family is pivotal, seems not to be appreciated sufficiently in many ethical analyses. A careful study of the family dimensions of may help in a small way to correct this blind spot.DefinitionBy physician-assisted suicide I mean a situation in which a patient kills him-or herself, using means which have been supplied by the physician, with the physician being aware that the patient intended to use those means for the purposes of suicide. Such cases generally arise with patients who suffer from terminal or irreversible, degenerative illnesses; although of course the presence of such an illness is not necessary for the definition to apply.The publicity surrounding Dr. Jack Kevorkian has led to an atypical public image of suicide. The patient's death is caused by an apparatus which the patient could not obtain or manipulate on his own; and the physician must be present at the time of death to set up the apparatus, even though the final action which throws the switch is the patient's and not the physician's. While few reliable data exist on the prevalence of any assisted practices in the U.S., it seems much more likely that the usual case of involves the physician giving the patient a lethal supply of pills, which the patient may (or may not) later elect to swallow as the disease progresses (Quill, 1991).The Family and the Decision to Request SuicideA patient seldom comes to a physician to request assistance with unless the decision has first been discussed within the family, or unless the family setting has in some way influenced the decision. Advocates of legalizing tend to view the family relationship among the potential safeguards which assure that a right to assistance will not be abused. …

Medical Decision Making and People with Disabilities: A Clash of Cultures

In discussions of medical decision making as it applies to people with disabilities, a major obstacle stands in the way: the perceptions and values of disabled people (particularly disability rights advocates and disabled social scientists) and of many nondisabled people (particularly health care professionals, ethicists, and health policy analysts), regarding virtually the whole range of current health and medical-ethical issues (treatment decision making, health care access and health care rationing, medical costcontainment, and assisted suicide), seem frequently to conflict with one another. This divergence in part grows out of the sense, common among people with disabilities, that their interactions with “the helping professions,” medical and social service professionals, are adversarial. But those differences of opinion also stem more basically from a clash of fundamental values.This paper addresses, in historical perspective, the ways in which the status of persons with disabilities as a stigmatized minority group affects medical decision making. It also examines the efforts of disability rights activists to prevent discrimination against persons with disabilities in current medical culture. Finally, it raises questions about how the rights of people with disabilities will fare as new care standards are developed and implemented.

The hyperreality of clinical ethics: A unitary theory and hermeneutics

Medical ethics nowadays is dominated by a conception of ethics as the application of moral theories and principles. This conception is criticized for its depreciation of the internal morality of medical practice and its narrow view of external morality. This view reflects both a lack of interest in the empirical realities of medicine and a neglect of the socio-cultural value-contexts of medical ethical issues, including the creative development of a broader philosophical framework for a practicable medical ethics. Several alternative approaches and conceptions have been proposed. The unified clinical ethics theory, developed by Graber and Thomasma, is an interesting attempt to synthesize these alternative approaches. It correctly identifies as the crucial problem the present disconnectedness of medical ethics from theoretical philosophy as well as the practice of medicine. In this paper, however, it is argued that the unitary theory should take more serious attention to the hermeneutic character of medicine as well as ethics. This implies that the unitary theory must in fact transform itself into an interpretive clinical ethics theory. The theoretical characteristics and practical consequences of an interpretive theory of medical ethics are discussed in the present paper.

Casuistry in medical ethics: Rehabilitated, or repeat offender?

For a number of reasons, casuistry has come into vogue in medical ethics. Despite the frequency with which it is avowed, the application of casuistry to issues in medical ethics has been given virtually no systematic defense in the ethics literature. That may be for good reason, since a close examination reveals that casuistry delivers much less than its advocates suppose, and that it shares some of the same weaknesses as the principle-based methods it would hope to supplant.

Is Informed Consent Needed for Fluorescein Angiography?

It is gratifying to see the recent increased attention given to issues of medical ethics in ophthalmology, in particular, the two excellent articles in the March 1993 issue of theArchiveson informed consent by Gold 1 and Finkelstein and colleagues. 2 Unfortunately, the accompanying article by Lee and colleagues 3 may seriously confuse many readers. Both its title (Is Informed Consent Needed for Fluorescein Angiography?) and large portions of its text (such as the entire first paragraph) seem to seriously suggest that there really is a question about whether informed consent is needed for fluorescein angiography. There is no question. As the article by Finkelstein et al correctly notes, informed consent, meaning a patient's informed agreement to a medical test or procedure, is a basic ethical mandate. It ought always to be obtained. 2 The question that Lee and colleagues 3 appear to be primarily interested in is how

Impact of clinical trial protocols on patient care systems at the University of Texas M.D. Anderson Cancer Center.

Clinical trial protocols represent a significant component of the research program at the University of Texas M.D. Anderson Cancer Center. Currently, there are nearly 800 active protocols using more than 150 investigational drugs. Sponsors of these trials include the National Cancer Institute, numerous pharmaceutical companies, and a variety of other funding sources. Because of our large patient base, however, routine participation in cooperative groups is limited. The impact of clinical trial protocols on patient care systems is a growing concern that is addressed primarily by the Surveillance Committee at M.D. Anderson. Like many institutional review boards, this committee reviews all protocols and must grant approval before the activation of any clinical trial. The issues of medical ethics, including a risk-benefit assessment for research subjects, equitable patient selection, safeguards for economically disadvantaged populations, and the general requirements for informed consent, also fall under the purview of this board. For any comprehensive cancer center to succeed, it must have strong research programs that enhance treatment options for patients. The crisis in financing health care significantly threatens the viability of cancer research. Reimbursement for the related costs of individuals participating in clinical trials has become a battle ground for third-party payers. The resulting economic risk is shared by health care providers and patients. As a consequence, many cancer centers, including M.D. Anderson, have initiated an economic-impact analysis for protocols as a component of the review process. This analysis includes an estimation of the patient care costs compared to the funding allocated to support the research. Future research will include pharmacoeconomic analysis and other ways to relate the costs and outcomes of treatment protocols. In the interim, we must monitor reimbursement trends for patients enrolled in clinical trials closely and amend the informed consent process to include a discussion of potential economic risk or hardship to patients if insurance claims are denied. Cancer care providers, third-party payers, the federal government, and society at large must work together to address the funding of cancer research and patient care.

Legal decisions affecting the limitation of nutritional support.

The withholding of nutritional support from patients is one of the most controversial issues in modern medical ethics and law. Withholding support from a consenting, terminally ill patient is the simplest case situation to defend, but patients in a persistent vegetative state or irreversible, chronic illness, require more careful deliberation. Regarding this issue, five primary principles have been utilized in legal decision making. These include: futility, autonomy, integrity of health professionals, states interests, balancing benefits versus harm and quality of life. The two landmark legal cases which have set the tone for most other court decisions are Paul Brophy and Nancy Beth Cruzan. Both cases clarified the right of competent adults to refuse nutritional support, even if life-saving. In the Cruzan case, however, states were given the authority to request clear and convincing evidence for the previous wishes of the incompetent patient. In summary, competent patients entering a hospice program should make informed decisions about their desires for feeding, as they do with other treatment decisions. Optimally, those wishes should be codified into an advance directive and a proxy decision maker named. If a patient is not competent, and without previously expressed wishes, immediate family members are usually consulted for what they believe are the patient's best interests. Last, although limitations of care for terminally ill children fall under the same general guidelines as for adults, the "Baby Doe Rules" are a complicating factor.

Electronic roundtables for medical ethics.

Electronic mail creates special opportunities and burdens for academicians and others. This article first describes e-mail and how it works in a university setting. It then presents the transcript of an electronic exchange of the issue of multiple or repeat abortion. The debate was inspired by a case presented during "ethics rounds" for students at a university medical center. The value of e-mail in this case is considered, and the electronic medium is found to be useful for sharing ideas and stimulating debate about issues in medical ethics, as well as for educational purposes.

The healer's power

In this provocative new book a philosopher-physician explores issues of medical ethics involved in a physician's use of power. Drawing from literary works dealing with medical power-from Dostoevsky's The Grand Inquisitor to stories by Richard Selzer-Dr. Howard Brody argues that proposals to reduce or eliminate the power of the physician are misguided; instead, guidelines should be developed for the use of medical power so that the physician shares with the patient both information and the responsibility for deciding on appropriate treatment. Some years ago, Brody, a physician with both clinical and academic obligations, began wondering why the concept of power so seldom entered into discussions of medical ethics...This solidly written and documented book is Brody's closely reasoned, thought-provoking analysis of that concept...An excellent text for-besides all levels of medical education-law discussion groups and individuals interested in the modern role of medicine.-Booklist A book with an intellectual energy, literate style, and sturdy originality ...We could not wish for a wiser guide than this book.-Michael Loudon, Lancet I find Brody's book fascinating. Surely, the concept of power is of critical importance in medical ethics. It is time that someone provide the serious, systematic examination of it that Brody offers. Brody is one of a very small group of physicians doing serious work in medical ethics. It is delightful to receive his newest contribution. His extensive use of literary material makes the chapters both novel and enjoyable reading.-Robert M. Veatch

Teaching of medical ethics in Sri Lanka.

Medical ethics as taught by members of the Department of Forensic Medicine in three of five medical colleges in Sri Lanka is a 'rule ethic' ('normative ethic') based on 'traditional' or 'classical' ethics. Instruction includes the teaching of moral principles, illustrated with examples. Also included are aspects concerning the functions of the Sri Lanka Medical Council. The topic is evaluated in the essay, multiple choice question and oral components of the third MBBS (Part II) examination (end of fourth year). As presently taught the syllabus is thoroughly inadequate for dealing with modern (medical) ethical issues. The shortcomings and limitations in the present programme are pointed out and requisite improvements suggested. A case is made for an eclectic view of ethics, in which a 'situation ethic' would play a part. Finally, the training of a highly moral responsible medical professional is emphasized.

The Patient-Physician Relation: The Patient as Partner, Part 2

This work by Robert Veatch is a collection of his essays (most already published, others written for it), which are brought together by their focus on the clinical relationship between physicians and patients. It is a companion volume to The Patient as Partner: A Theory of Human-Experimentation Ethics (Indiana University Press, 1987), which examined research in medicine. The subjects explored are important and varied. Essays appear on doctors as strangers, principles of medical ethics, informed consent, deciding what patients should know, prescribing placebos, duties of patients, cost-containment, risk-taking behavior, transplantation, guardianship, do-not-resuscitate orders, and institutional ethics committees. This list reveals the breadth of the book, which provides a wealth of commentary on central issues in medical ethics. This breadth also is a source of weakness. The essays, written at different times for different audiences, though often connected by newly written transitional paragraphs, nevertheless do not create a coherent whole. This