Medicine, lies and deceptions

This article offers a qualified defence of the view that there is a moral difference between telling lies to one's patients, and deceiving them without lying. However, I take issue with certain arguments offered by Jennifer Jackson in support of the same conclusion. In particular, I challenge her claim that to deny that there is such a moral difference makes sense only within a utilitarian framework, and I cast doubt on the aptness of some of her examples of non-lying deception. But I argue that lies have a greater tendency to damage trust than does non-lying deception, and suggest that since many doctors do believe there is a moral boundary between the two types of deception, encouraging them to violate that boundary may have adverse general effects on their moral sensibilities.     

Telling the truth.

Are doctors and nurses bound by just the same constraints as everyone else in regard to honesty? What, anyway, does honesty require? Telling no lies? Avoiding intentional deception by whatever means? From a utilitarian standpoint lying would seem to be on the same footing as other forms of intentional deception: yielding the same consequences. But utilitarianism fails to explain the wrongness of lying. Doctors and nurses, like everyone else, have a prima facie duty not to lie--but again like everyone else, they are not duty-bound to avoid intentional deception, lying apart; except where it would involve a breach of trust.     

On the morality of deception--does method matter? A reply to David Bakhurst.

Does it signify morally whether a deception is achieved by a lie or some other way? David Bakhurst has challenged my view that it can signify. Here I counter his criticisms--firstly, by clarifying the terminology: What counts as a lie? Secondly, by exploring further what makes lying wrong. Bakhurst maintains that lying is wrong in that it infringes autonomy--and other deceiving stratagems, he says, do so equally. I maintain that lying is wrong in that it endangers trust--and other types of deceiving stratagems do not do so equally. Lying to patients, I contend, is an abuse of their trust. Other forms of their intentional deception need not be so, although, in our autonomy-minded culture, they are likely to be so.     

Placebos: the nurse and the iron pills

In sub‐Saharan Africa, a nurse gives iron pills as placebos to terminally ill patients. She tells them, acting in what she believes is in their best interests, “these will make you feel better”. The patients believe it will help their AIDS and their well‐being improves. Do the motive and the patient''s positive outcome in well‐being make the deceit justifiable when other issues such as consent, autonomy and potential consequences regarding the patient and the wider community are considered? Is there a difference between lying and non‐lying deception when the end result is the same? The patients feel better, but at what cost if the deceit was found out? It will be argued that although the actions of the nurse are understandable and to some extent defensible, they are unethical. It is not ethically acceptable to take away the patient''s autonomy and risk the health of the community even though the risk of deceit being discovered is a small one.This is a true case, witnessed first‐hand on a recent visit to sub‐Saharan Africa. A community HIV nurse visits a rural village to provide home‐based care for terminally ill patients with AIDS. The active treatment for AIDS (antiretroviral drugs) is either unavailable or unaffordable to her patients and the nurse cannot provide such treatment. Instead, she gives placebos in the form of iron tablets to her patients. She says to them “these will make you feel better”. The implication and the interpretation of these words from the patient''s perspective is that it will improve their AIDS.There are many moral and ethical issues surrounding this case. The nurse is knowingly giving the patients treatment that is ineffective for their condition. The nurse is very experienced in this field and believes that the act of taking medicines that are believed to be active, her patients feel an improvement in their health. She believes that she is doing the right thing as she is fulfilling what she sees as her role—making her patients feel better.However, independent of whether or not giving placebos is morally right, the underlying ethical issue in this case is the deception. Although the motive for the deception was in good faith, the nurse intentionally implies that the medicine is helping the AIDS. Do the motive and the patient''s positive outcome make the deceit justifiable when other issues such as consent, autonomy and potential consequences regarding the patient and the wider community are considered?     

Participation in biomedical research is an imperfect moral duty: a response to John Harris

In his paper "Scientific research is a moral duty", John Harris argues that individuals have a moral duty to participate in biomedical research by volunteering as research subjects. He supports his claim with reference to what he calls the principle of beneficence as embodied in the "rule of rescue" (the moral obligation to prevent serious harm), and the principle of fairness embodied in the prohibition on "free riding" (we are obliged to share the sacrifices that make possible social practices from which we benefit). His view that biomedical research is an important social good is agreed upon, but it is argued that Harris succeeds only in showing that such participation and support is a moral good, among many other moral goods, while failing to show that there is a moral duty to participate in biomedical research in particular. The flaws in Harris's arguments are detailed here, and it is shown that the principles of beneficence and fairness yield only a weaker discretionary or imperfect obligation to help others in need and to reciprocate for sacrifices that others have made for the public good. This obligation is discretionary in the sense that the individuals are free to choose when, where, and how to help others in need and reciprocate for earlier sacrifices. That Harris has not succeeded in claiming a special status for biomedical research among all other social goods is shown here.     

Stem cell research on other worlds, or why embryos do not have a right to life

Anxieties about the creation and destruction of human embryos for the purpose of scientific research on embryonic stem cells have given a new urgency to the question of whether embryos have moral rights. This article uses a thought experiment involving two possible worlds, somewhat removed from our own in the space of possibilities, to shed light on whether early embryos have such rights as a right not to be destroyed or discarded (a "right to life"). It is argued that early embryos do not have meaningful interests or any moral rights. Accordingly, claims about the moral rights of embryos do not justify restrictions on stem cell research.     

法学视野下的“临终关怀权”

临终关怀在提升临终病患生命质量、维护其尊严方面得到越来越多的认可。本文从法学视野对临终关怀权进行探索性研究,主要针对权利主体、义务主体、权利内容与义务内容等方面进行分析,提出临终关怀权的权利主体目前应限定于不可挽救的、临终遭受较大痛苦的病患,义务主体应确定为国家政府、亲属、特定医疗机构等,权利内容包括自由权、请求权等。     

Good parents would not fulfil their obligation to genetically enhance their unborn children

The purpose of this paper is to unveil the incompleteness of John Harris' view that parents have a moral obligation to genetically enhance their unborn children. Specifically, here two main conclusions are proposed: (1) at present there exist insufficient empirical data for determining whether prenatal genetic enhancement (PGE) is a moral obligation on prospective parents. Although the purpose of PGE research would be to determine the extent to which PGE is safe and effective, the task of determining the veracity of Harris' premises is impossible to achieve without begging the question; we would be forced to assume the moral permissibility of PGE in order to generate the data that are required for determining its moral standing. So, given this empirical blindness, consequence-based normative frameworks like that of Harris cannot determine the moral standing of PGE, but merely push the question of the moral standing of PGE back a step, without offering any plausible and morally endorsable recourse for how to answer it; (2) even if PGE research were legal, which it is not, parents nevertheless have good reason not to consent to it for their children, especially as participants in the first wave(s) of such research.     

论基本医疗卫生服务法律制度建设

公民在重病危难之时获得国家提供的基本医疗卫生服务,属于基本道德权利,这种基本道德权利从政府的角度来看,就是基本道德义务;而且,随着《公民经济、社会和文化权利国际公约》确认缔约国在尊重、实现和保护公民健康权方面,有满足最起码的和最低水平的健康保障的核心义务,我国在立法上确保人人有权获得基本医疗卫生服务,将这种基本道德权利上升为法律权利,成为必然要求。为此,应当制定＂基本医疗卫生服务法＂,建立基本医疗卫生服务的普遍保障、医疗保险加国家救助、基本保障、倾斜保护、公益性和民主管理等六项基本法律制度;相关的具体制度建设、变革和创新,则可随着社会条件和需求的变化,作适度调整。文章参考国际和外国大量立法、案例和理论作了必要探讨。     

Problems in deceptive medical procedures: an ethical and legal analysis of the administration of placebos

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 where full disclosure 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.     

试论医院维权与自律的关系

从维权与自律的概念入手,分析了伦理学界定的自律与医院自律公约的区别,认为维权只有当侵权发生后才被重视,维权应以法律为依据。从三个方面阐述了维权与自律的关系:从工作上看,自律是维权的基础;从典型案例看,二者虽有一定关系但无必然联系;从理论上看,二者分属法学与伦理学范畴,法与道德在卫生领域有着诸多特殊性;鉴于目前医院作为法人的权利尚不明晰,建议尽快制定医院权益的有关规定,以指导医院的维权工作。     

Parental procreative obligation and the categorisation of disease: the case of cystic fibrosis

The advent of prenatal genetic diagnosis has sparked debates among ethicists and philosophers regarding parental responsibility towards potential offspring. Some have attempted to place moral obligations on parents to not bring about children with certain diseases in order to prevent harm to such children. There has been no rigorous evaluation of cystic fibrosis in this context. This paper will demonstrate cystic fibrosis to have unique properties that make it difficult to categorize among other diseases with the goal of promulgating a reproductive rule. Once this is established, it will be demonstrated that procreative rules that appeal to future health are inadequate in the era of advancing genetic knowledge. Utilising a specification of Joel Feinberg's 'open future' concept outlined by Matteo Mameli, it will offer an analysis of parental obligation that does not constrain parents of potential children with cystic fibrosis with a moral obligation not to bring them about.     

Strikes and the National Health Service: Some legal and ethical issues

This paper is sadly opportune. The general public is angry and bewildered if not hurt by the variety of strikes which are brought more or less forcibly to their attention. People used to understand what lay behind a strike - a demand for more pay, better conditions - but today a political element often intrudes, and it is this that worries those who ask themselves whether this or that dispute is either lawful or morally acceptable.

Professor Dworkin, a lawyer, first sets out the legal issues surrounding strikes and then advances the ethical arguments, closely relating them to the legal framework. The most interesting part of the paper, however, may well be that devoted to the moral obligation of example, in particular the example to be set by members of the medical profession and by all those caring for the sick. As public attitudes to industrial disputes `become dulled and quiescent' it is absolutely necessary that there should be a reappraisal of the moral standards of the past which coincide with a respect for the law. In the last century the term `anomie' was used to describe a `society which has shaken off its former restraints such as religion, respect for law and order and a definite moral code as to what is right and wrong'. We are living in that sort of society today, and one need not be a professional `ethicist' to recognize the signs, and hopefully, to work for the return of `ethical' values.

     

Rights theory in a specific healthcare context: "speaking ill of the dead"

Generally physicians have a legal and ethical obligation of keeping confidentiality regarding their communication with patients and it is clear that we all have rights. The application of rights theorem, which usually refers to the recognition of individual human rights, to the deceased offers possible answers to the problematic question of patient confidentiality after death. Philosophical considerations broadly support utilitarian ideals concerning the 'common good'. However, it may be possible to rank rights according to a hierarchy of need and thus preserve individual rights where they do not impinge upon the public's right to protection from harm and the physician's right to tell the truth. This has broad implications for confidentiality, anonymity and health care information in general for patients, their families and healthcare workers. We discuss these issues, with specific reference to an individual case.     

从天赋人权到大自然的权利

文章论述了从天赋人权到动物权利再到大自然权利的伦理变迁过程。揭示出人类在环境保护问题上必须实现价值观念的根本转变－－走出人类中心主义，重建生态伦理观，自觉地担当起对整个自然界的责任和义务。     

Must doctors save their patients?

Do doctors and other medical staff have an obligation to treat those who need their help? This paper assumes no legal or contractual obligations but attempts to discover whether there is any general moral obligation to treat those in need. In particular the questions of whether or not the obligation that falls on medical staff is different from that of others and of whether doctors are more blameworthy than others if they fail to treat patients are examined. Finally we look at the question of the burden of this obligation and at the responsibility of society to mitigate its hardships.     

Andrew Jackson's exposure to mercury and lead: poisoned president?

Historians have suggested that US president Andrew Jackson (1767-1845) experienced lead and mercury poisoning following his therapeutic use of calomel (mercurous chloride) and sugar of lead (lead acetate). To evaluate these claims, we performed direct physical measurement of 2 samples of Jackson's hair (1 from 1815, 1 from 1839). Following pretreatment and acid digestion, mercury was measured using cold vapor generation techniques, while lead levels were measured by electrothermal atomic absorption spectrophotometry. Mercury levels of 6.0 and 5.6 ppm were obtained from the 1815 and 1839 hair specimens, respectively. Lead levels were significantly elevated in both the 1815 sample (mean lead level, 130.5 ppm) and the 1839 sample (mean lead level, 44 ppm). These results suggest that Jackson had mercury and lead exposure, the latter compatible with symptomatic plumbism in the 1815 sample. However, Jackson's death was probably not due to heavy metal poisoning.     

Bodies, rights and abortion.

The issue of abortion is discussed with reference to the claim that people have a right of control over their own bodies. Do people "own" their own bodies? If so, what would be entailed? These questions are discussed in commonsense terms and also in relation to the jurisprudence of Hohfeld, Honore, Munzer and Waldron. It is argued that whether or not women are morally and/or should be legally entitled to have abortions, such entitlements cannot be derived from a general moral entitlement to do what we will with our own bodies since there is no such entitlement. Whether or not we "own" them, we can have rights duties, liabilities, restrictions and disadvantages as well as rights concerning our own bodies.     

Should desperate volunteers be included in randomised controlled trials?

Randomised controlled trials (RCTs) sometimes recruit participants who are desperate to receive the experimental treatment. This paper defends the practice against three arguments that suggest it is unethical first, desperate volunteers are not in equipoise. Second clinicians, entering patients onto trials are disavowing their therapeutic obligation to deliver the best treatment; they are following trial protocols rather than delivering individualised care. Research is not treatment; its ethical justification is different. Consent is crucial. Third, desperate volunteers do not give proper consent: effectively, they are coerced. This paper responds by advocating a notion of equipoise based on expert knowledge and widely shared values. Where such collective, expert equipoise exists there is a prima facie case for an RCT. Next the paper argues that trial entry does not involve clinicians disavowing their therapeutic obligation; individualised care based on insufficient evidence is not in patients best interest. Finally, it argues that where equipoise exists it is acceptable to limit access to experimental agents; desperate volunteers are not coerced because their desperation does not translate into a right to receive what they desire.     

新时期改善医德医风的途径探讨

新时期改善医德医风要做到以医疗体制的完善来促使医德医风的改善;以道德义务和道德权利的对等来保障"德福一致"的实现;以医患沟通来平衡医患之间的信息不对称;以制度伦理建设来建立和谐的医患关系.