Medical ethics

Three current issues in biomedical ethics are briefly reviewed: discontinuance of artificial feeding, acquired immunodeficiency syndrome (AIDS), and the physician as economic "gatekeeper." The controversy surrounding artificial feeding is illustrated through a summary of three recent court cases (Brophy in Massachusetts, Jobes in New Jersey, and Bouvia in California). AIDS is engendering heated debate on questions such as the physician's duty to care, public health efforts to stem spread of the disease, and policy issues related to resource allocation. Efforts to control health care costs through prospective payment arrangements are confronting physicians with a serious conflict between their economic interests and ethical obligations.     

Ethical aspects of clinical chemistry.

The work performed by the clinical chemist may deeply affect the decisions of the doctor and the well-being of the patient. Yet in contrast to the doctor and to the nurse the clinical chemist usually has no personal relationship with the patient. Being encumbered by much technology and anonymity is itself a reason for scrutinising his involvement in issues of health care ethics. This is an attempt at clarifying some major aspects: the relationship of his professional ethics to medical ethics as a whole, his ethical obligations to the patient and to society, and other aspects.     

Integrating cost awareness with ethics in the undergraduate medical curriculum

The challenge to train medical students in cost awareness regarding medical care led to a program at the Oregon Health Sciences University that integrates concern for costs with medical ethics. Cost awareness is a perspective that balances the physician's ethical obligations toward individual patients with their duties toward society whose pooled resources pay for medical services. The program integrates the subject of cost awareness into major required courses spanning the four-year curriculum. First-year students see costs in the context of an overview of social aspects of medical care. For second-year students, cost awareness is incorporated into training in basic clinical skills. Third- and fourth-year students are shown the bill for one of their patients and analyze their ward experiences from the perspective of resource utilization. Junior and senior students examine the impact of the legal system and professional ethics on health care costs. Elective course work on cost awareness is also available.     

Ethics

In the annual Contempo issue, the editors of the Journal of the American Medical Association publish updates by experts in selected specialties of major issues and innovations in various subfields of medicine. Pellegrino's Contempo '90 essay on ethics focuses on the ethical impact of recent AIDS research, particularly the availability of early treatment with drugs that, while not curative, may prolong and enhance the quality of life for persons with AIDS. Among the issues Pellegrino highlights are screening and confidentiality, access to care and clinical trials, the design of clinical trials, the obligations of health personnel and of persons with AIDS, resource allocation, and needle exchange programs.     

从伦理学角度看灾后重建过程中卫生资源的公平性配置

近年来,地震、泥石流、洪水等重大自然灾害的侵袭,给我国经济和社会发展造成了巨大的损失。在灾后重建工作中,卫生系统占有举足轻重的地位,其核心是卫生资源的重新配置。卫生资源配置的水平和效果直接影响着重建效果和卫生服务水平。效率与公平是卫生资源配置的2个准则,如何在保证配置效率最大化的同时,坚持公平的价值取向和伦理诉求,实现包括健康权利、资源分布和制度保障等方面的公平性目标,需要从伦理学的角度进行深入思考。     

Patients' ethical obligation for their health.

In contemporary medical ethics health is rarely acknowledged to be an ethical obligation. This oversight is due to the preoccupation of most bioethicists with a rationalist, contract model for ethics in which moral obligation is limited to truth-telling and promise-keeping. Such an ethics is poorly suited to medicine because it fails to appreciate that medicine's basis as a moral enterprise is oriented towards health values. A naturalistic model for medical ethics is proposed which builds upon biological and medical values. This perspective clarifies ethical obligations to ourselves and to others for life and health. It provides a normative framework for the doctor-patient relationship within which to formulate medical advice and by which to evaluate patient choice.     

Bioethics for clinicians: 13. Resource allocation

Questions of resource allocation can pose practical and ethical dilemmas for clinicians. In the Aristotelian conception of distributive justice, the unequal allocation of a scarce resource may be justified by morally relevant factors such as need or likelihood of benefit. Even using these criteria, it can be difficult to reconcile completing claims to determine which patients should be given priority. To what extent the physician's fiduciary duty toward a patient should supersede the interests of other patients and society as a whole is also a matter of controversy. Although the courts have been reluctant to become involved in allocation decisions in health care, they expect physicians to show allegiance to their patients regardless of budgetary concerns. The allocation of resources on the basis of clinically irrelevant factors such as religion or sexual orientation is prohibited. Clear, fair and publicly acceptable institutional and professional policies can help to ensure that resource allocation decisions are transparent and defensible.     

公正伦理视阈下的平价医院研究

近几年来,中国的医疗体制改革问题始终是社会热点问题。从伦理学层面来剖析,问题的核心应首先聚焦于医疗公正。医疗公正不仅是医学道德的重要伦理原则,而且从根本上说是社会公正的正义。平价医院的诞生凸显了医疗公正的伦理价值,有助于缓解社会弱势群体的医疗卫生保健问题,进而有利于实现社会的真正和谐。     

医疗机构及医务人员的伦理困境与法律对策

在医疗伦理损害责任背景下,医疗机构及其医务人员在具体履行医疗告知义务时、患者(特定情况下其近亲属)知情不同意时、以及面临具体法之局限性时,常常陷于对患者的知情权、生命健康权、自主决定权、乃至自身的法律责任风险进行个人抉择的伦理困境。尽管导致伦理困境的原因是多方面的,但从法律视角来看,制定明确、规范的医疗伦理行为指引,建立解决医疗伦理困境的常设机构,健全医疗风险规避、医疗社会保障和医疗伦理督察制度,应是现实可行的应对之策。     

Ethical issues in predictive genetic testing: a public health perspective

As a result of the increase in genetic testing and the fear of discrimination by insurance companies, employers, and society as a result of genetic testing, the disciplines of ethics, public health, and genetics have converged. Whether relatives of someone with a positive predictive genetic test should be notified of the results and risks is a matter urgently in need of debate. Such a debate must encompass the moral and ethical obligations of the diagnosing physician and the patient. The decision to inform or not will vary depending on what moral theory is used. Utilising the utilitarian and libertarian theories produces different outcomes. The principles of justice and non-maleficence will also play an important role in the decision.     

Ethical principles in critical care

Luce applies five principles of medical ethics -- beneficence, nonmaleficence, autonomy, disclosure, and social justice -- to issues that often arise in critical care medicine. These issues include medical decision making, informed consent, resuscitation, brain death and organ donation, withholding or withdrawing life support, and allocation of medical resources. Acknowledging that the nature of the intensive care environment makes applying ethical principles difficult, Luce urges physicians to carry out their obligations to serve the interests of their patients.     

In defence of medical ethics.

A number of recent publications by the philosopher David Seedhouse are discussed. Although medicine is an eminently ethical enterprise, the technical and ethical aspects of health care practices can be distinguished, therefore justifying the existence of medical ethics and its teaching as a specific part of every medical curriculum. The goal of teaching medical ethics is to make health care practitioners aware of the essential ethical aspects of their work. Furthermore, the contention that rational bioethics is a fruitless enterprise because it analyses non-rational social events seems neither theoretically tenable nor to be borne out by actual practice. Medical ethics in particular and bioethics in general, constitute a field of expertise that must make itself understandable and convincing to relevant audiences in health care.     

Ethical practice in internet research involving vulnerable people: lessons from a self-harm discussion forum study (SharpTalk)

The internet is widely used for health information and support, often by vulnerable people. Internet-based research raises both familiar and new ethical problems for researchers and ethics committees. While guidelines for internet-based research are available, it is unclear to what extent ethics committees use these. Experience of gaining research ethics approval for a UK study (SharpTalk), involving internet-based discussion groups with young people who self-harm and health professionals is described. During ethical review, unsurprisingly, concerns were raised about the vulnerability of potential participants. These were dominated by the issue of anonymity, which also affected participant safety and consent. These ethical problems are discussed, and our solutions, which included: participant usernames specific to the study, a closed website, private messaging facilities, a direct contact email to researchers, information about forum rules displayed on the website, a 'report' button for participants, links to online support, and a discussion room for forum moderators. This experience with SharpTalk suggests that an approach to ethics, which recognises the relational aspects of research with vulnerable people, is particularly useful for internet-based health research. The solutions presented here can act as guidance for researchers developing proposals and for ethics committees reviewing them.     

How physician executives and clinicians perceive ethical issues in Saudi Arabian hospitals

OBJECTIVES: To compare the perceptions of physician executives and clinicians regarding ethical issues in Saudi Arabian hospitals and the attributes that might lead to the existence of these ethical issues. DESIGN: Self-completion questionnaire administered from February to July 1997. SETTING: Different health regions in the Kingdom of Saudi Arabia. PARTICIPANTS: Random sample of 457 physicians (317 clinicians and 140 physician executives) from several hospitals in various regions across the kingdom. RESULTS: There were statistically significant differences in the perceptions of physician executives and clinicians regarding the existence of various ethical issues in their hospitals. The vast majority of physician executives did not perceive that seven of the eight issues addressed by the study were ethical concerns in their hospitals. However, the majority of the clinicians perceived that six of the same eight issues were ethical considerations in their hospitals. Statistically significant differences in the perceptions of physician executives and clinicians were observed in only three out of eight attributes that might possibly lead to the existence of ethical issues. The most significant attribute that was perceived to result in ethical issues was that of hospitals having a multinational staff. CONCLUSION: The study calls for the formulation of a code of ethics that will address specifically the physicians who work in the kingdom of Saudi Arabia. As a more immediate initiative, it is recommended that seminars and workshops be conducted to provide physicians with an opportunity to discuss the ethical dilemmas they face in their medical practice.     

对“知情不同意”情况下医疗不作为的伦理学审视

伦理在法律实施中的价值以及道德义务与法律义务之间的辩证关系决定了“不作为”既是一种法律判断,又是一种伦理判断。知情不同意情况下,医疗不作为的发生有医患关系紧张导致医务人员角色混乱、知情同意制度存在缺陷以及医疗高风险缺乏保护等深层次原因。为此,需要加强医务人员职业精神建设、充分发挥医院伦理委员会的作用,不断健全相关法律制度。     

Ethics, EBM, and hospital management

Matters of hospital management do not figure prominently on the medical ethics agenda. However, management decisions that have to be taken in the area of hospital care are in fact riddled with ethical questions and do have significant impact on patients, staff members, and the community being served. In this decision making process evidence based medicine (EBM) plays an increasingly important role as a tool for rationalising as well as rationing health care resources. In this article, ethical issues of hospital management and the role of EBM will be explored, with particular reference to disease management programs, diagnosis related groups, and clinical pathways as recent developments in the German health care system.     

Ethics, economics, and public financing of health care

There is a wide variety of ethical arguments for public financing of health care that share a common structure built on a series of four logically related propositions regarding: (1) the ultimate purpose of a human life or human society; (2) the role of health and its distribution in society in advancing this ultimate purpose; (3) the role of access to or utilisation of health care in maintaining or improving the desired level and distribution of health among members of society, and (4) the role of public financing in ensuring the ethically justified access to and utilisation of health care by members of society. This paper argues that economics has much to contribute to the development of the ethical foundations for publicly financed health care. It focuses in particular on recent economic work to clarify the concepts of access and need and their role in analyses of the just distribution of health care resources, and on the importance of economic analysis of health care and health care insurance markets in demonstrating why public financing is necessary to achieve broad access to and utilisation of health care services.     

Caring for seriously ill and dying patients: the philosophy and ethics.

The care of seriously ill and dying patients necessitates a philosophic and ethical basis, without which unacceptable patterns of practice may develop. Several problems are described: inadequate or unskilled communication of information, withdrawal by the physician, patient labelling and poor health care. Palliative care must be based on a philosophy that acknowledges the inherent worth and dignity of each person. In addition, it must take place within the framework of four ethical principles: autonomy, beneficience, nonmaleficience and justice. The first and most important of these is the need to regard patients as unique people with a right to compassion, gentle truth, autonomy in decision-making and excellence in physicial and psychospiritual care. Beneficence obliges us not only to relieve suffering but also to enhance the patient's quality of life whenever possible. Nonmaleficence and justice require allocation of sufficient health care resources of the type necessary to provide high-quality care and prevent patients from coming to harm.     

Challenges in ethics, safety, best practices, and oversight regarding HIT vendors, their customers, and patients: a report of an AMIA special task force

The current commercial health information technology (HIT) arena encompasses a number of competing firms that provide electronic health applications to hospitals, clinical practices, and other healthcare-related entities. Such applications collect, store, and analyze patient information. Some vendors incorporate contract language whereby purchasers of HIT systems, such as hospitals and clinics, must indemnify vendors for malpractice or personal injury claims, even if those events are not caused or fostered by the purchasers. Some vendors require contract clauses that force HIT system purchasers to adopt vendor-defined policies that prevent the disclosure of errors, bugs, design flaws, and other HIT-software-related hazards. To address this issue, the AMIA Board of Directors appointed a Task Force to provide an analysis and insights. Task Force findings and recommendations include: patient safety should trump all other values; corporate concerns about liability and intellectual property ownership may be valid but should not over-ride all other considerations; transparency and a commitment to patient safety should govern vendor contracts; institutions are duty-bound to provide ethics education to purchasers and users, and should commit publicly to standards of corporate conduct; and vendors, system purchasers, and users should encourage and assist in each others'' efforts to adopt best practices. Finally, the HIT community should re-examine whether and how regulation of electronic health applications could foster improved care, public health, and patient safety.     

Ethical dilemmas in occupational therapy and physical therapy: a survey of practitioners in the UK National Health Service.

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.