Showing papers by "Arthur L. Caplan published in 1997"

Everyday Matters in the Lives of Nursing Home Residents: Wish for and Perception of Choice and Control

Abstract: OBJECTIVES: This study examined the importance that nursing home residents and nursing assistants ascribed to control and choice over everyday issues, the satisfaction of residents with their control and choice over these issues, and the nursing assistants' impressions of the extent to which control and choice exist for nursing home residents on everyday matters. DESIGN: Cross-sectional in-person interviews with a stratified representative sample of nursing home residents and nursing assistants using semi-structured interview protocols with both fixed-choice and open-ended questions. SETTING: A random sample of 25 nursing homes in the Twin Cities, MN area; a random sample of five nursing homes in North Little Rock, AR; all five nursing homes in Sante Fe, NM; and five purposively selected nursing homes in each of New York City and Los Angeles, CA. PARTICIPANTS: One hundred thirty-five cognitively intact residents, three from each facility, were selected and included the resident council chair, one randomly selected short-stay resident, and one randomly selected long-stay resident from each facility. Also participating were 134 nursing assistants (1 selected randomly from each shift from those employed at least two-thirds time and who had worked in the facility for at least 3 months). MEASUREMENTS: The most important measurements were ordinal-level ratings of the importance of choice and control for nursing home residents over 10 selected areas of everyday life; ordinal measures of residents' satisfaction with their choice and control over these areas; and nursing assistants' ratings of the extent to which they thought it possible for residents to achieve choice and control. Open-ended comments were also elicited. Also measured were demographic data, ADL status, frequency of trips away from the nursing home, frequency of receiving visitors, and (for nursing assistants) length of employment, wages, job satisfaction, and extent to which they knew the residents under their care. MAJOR RESULTS: Cognitively intact nursing home residents attach importance to choice and control over matters such as bedtime, rising time, food, roommates, care routines, use of money, use of the telephone, trips out of the nursing home, and initiating contact with a physician. Nursing assistants view such control as important to residents. Residents and staff differ significantly in the importance attached to particular items, with staff placing lower importance than residents on use of the telephone and personal expenditures and higher importance on control and choice over visitors and formal nursing home activities. Residents were not very satisfied with their control and choice, and nursing assistants viewed them as unlikely to experience control and choice. Nursing home, resident, and staff characteristics were not associated with the patterns of results. CONCLUSIONS: A self-defeating cycle has been identified where neither resident nor staff are optimistic about achieving more resident control and choice, which both groups perceive as desirable. To end this cycle, suggestions are offered for structuring the role of the nursing assistant, physician and nurse leadership, changes in nursing home routines and practices, and public policy changes.

Fair Allocation of Intensive Care Unit Resources

Abstract: T HIS OFFICIAL STATEMENT OF THE A MERICAN T HORACIC S OCIETY WAS ADOPTED BY THE ATS B OARD OF D IRECTORS , M ARCH 1997. SUMMARY American Thoracic Society (ATS) members, as health care practitioners caring for critically ill patients in intensive care units (ICUs) or as ICU directors, commonly must make decisions that allocate ICU resources. Some decisions necessitate prioritization of ICU beds while others limit access to particular scarce resources. Although these decisions arise when providing medical care for ICU patients, they occur in a larger context that includes ethical, economic, social, and legal considerations. In this context health care systems in the United States and in other countries face the consequences of increasing demand for expensive health care services in times of limited financial resources and competing societal needs. If one accepts the premise that demand for health care resources will inevitably outstrip financial constraints, one then must face the basic question of how to allocate those resources fairly. How health care organizations will meet increasing demand for services within financial constraints raises specific questions relating to the fair allocation of ICU resources:

Nondirectiveness in genetic counseling: A survey of practitioners

Abstract: The literature defines nondirectiveness as a genetic counseling strategy that supports autonomous decision-making by clients [Fine, 1993]. This study surveyed 781 full members of the National Society of Genetic Counselors (NSGC) between April and June, 1993, to assess how they define nondirectiveness, its importance to their practice, and how and why they are ever directive. Almost 96% of 383 respondents reported viewing nondirectiveness as very important, but 72% stated they are sometimes directive. The most common reasons for directiveness include: difficulties ensuring that verbal and nonverbal cues remain nondirective; to recommend testing; client is unable to understand; a better choice is clear; to recommend medical care or counseling; or when a client has difficulty making a decision. Nonsignificant Chi-square analyses indicated that counselor responses were independent of counselor demographics. While these findings suggest that nondirectiveness is a goal in genetic counseling, it is not the only goal. Recognition of the delicate balance between directing the process and defining the outcome of genetic counseling can enhance clinicians' ability to discern the circumstances under which directiveness is and is not appropriate.

Crisis, Ethics, and the American Medical Association 1847 and 1997

Abstract: American medicine in 1997: the core values of the medical profession are being decided, not by physicians and surgeons acting through medical societies, but by lawyers and judges taking action in courtrooms and by managed care administrators overriding the decisions of trained medical professionals in response to the imperatives of commodified medicine. American medicine is in crisis. To put this crisis in perspective, however, consider the state of medicine in the United States 150 years ago. Licensing laws had been repealed as "elitist" and "antidemocratic." 1(pp43 -63) The New York physician Nathan Smith Davis (1817-1904) reported that, in the absence of minimal licensing standards, "The college that offered to confer [an MD] after attendance on the shortest annual courses of instruction and the lowest college fees could generally draw the largest class." 2 Consequently, as Dr Nathaniel Chapman (1780-1853) of Philadelphia remarked, "The too ready admixture into [medicine] of individuals

The Ethics of Gatekeeping in Rehabilitation Medicine

Abstract: Everywhere one looks in health care, concern is being expressed about the ethical issues raised by efforts to contain costs. Managed care bears much of the brunt of these concerns. Many health policy analysts argue that the central issue raised by the need to contain costs is the need to arrive at a set of rules or principles that will permit the fair and equitable allocation of resources. However, the main moral challenge posed by cost containment is not arriving at agreed-upon principles. Rather, it is the moral dilemma created when health care providers are asked to serve in the roles of both bedside patient advocate and guardian of societal resources. This is especially true in the field of rehabilitation medicine, where patients often cannot protect their own interests due to impairments of competency or loss of freedom as a result of institutionalization, or because they find it hard to deal with the team approach, In which the locus of authority can be difficult to determine.

Due Consideration: Controversy in the Age of Medical Miracles

Abstract: Abortion and Birth Control. Genetics. Technological Reproduction. The Ethics of Research. New Treatment/New Challenges. Rationing Cost. Managed Care. Starting and Stopping Care. Assisted Suicide. Aids and Other Plagues. Smoking and Other Bad Habits.

Will assisted suicide kill hospice

Abstract: Hospice is often held out as an alternative to the need for assisted suicide. To date, those in the hospice movement have made any discussion of assistance in dying off-limits on the grounds that proper palliative care can address the concerns about pain that the terminally ill face. But, the movement toward assisted suicide raises questions about the future viability of the hospice movement in its current form. Many who see assistance in dying are concerned, not about pain, but about suffering and loss of dignity. Many are not terminally ill but terrified at the prospect of disability and loss of cognitive capacities. Unless hospice addresses these concerns it is not likely to survive in the face of pressures to legalize assisted suicide.

The unclaimed cadaver.

Abstract: No abstract available.

The Human Genome Project and the future of health care.

Abstract: The human genome project and the future of health care. Thomas H. Murray, Mark A. Rothstein, & Robert F. Murray, Jr., Eds. (Indiana University Press, Bloomington, Indiana, 1996), 264 pages (clothbound), $29.95.

Using one's head.

Abstract: A recent News & Comment item by Oliver Morton (“First Dolly, now headless tadpoles,” [31 Oct., p. 798][1]), arrives at the conclusion that the flurry of interest that surrounded news reports about the prospect of cloning headless humans as sources of organs for transplant was “ephemeral.” We wish that were so. The article also points the finger of blame in the direction of the media in Europe and the United States eager for hype and sensationalism. Again, we wish that were the only source of blame for this latest chapter in the public misunderstanding of advances in genetics. The intensity of the media coverage that followed in the wake of the announcement that cloning might be used to make headless bodies for mining organs and tissues is not well described as “ephemeral.” The intense media coverage of the sort that greeted this article guarantees it will have a very long life in the public mind. That scientists are partly to blame for this state of affairs is something that is hard to admit. But it ought to be acknowledged. Jonathan Slack of the University of Bath in southwestern England made tadpole embryos that have just bodies and others that apparently have just heads. This research led him to pronounce to a BBC television documentary crew preparing a film on cloning that perhaps the same could usefully be done in people. A torrent of silliness was unleashed as word of an impending world of decerebrate humanity leaked out to the general press in Europe and North America. Lest anyone think that scientists stood horrified while these events unfolded, it should be noted that a former head of the National Institutes of Health got into the act, declaring on the CBS Evening News that the purposeful creation of human mutants for organ harvesting would be “ghoulish” and “chilling” because embryos without brains “would have zero potential to say no.” It is certainly true that headless humans would find it hard to “just say no.” But the whole idea of a debate about the merits of headless clones is absurd on both scientific and moral grounds. People without heads are dead. To use them as organ sources, one would need to keep their bodies functioning. Getting a human being born and to adulthood without a head would be a virtually impossible task. Morally, the idea is also ridiculous. Intentionally creating defective human bodies would not be an acceptable use of genetic science. The mass production of bodies without brains would cheapen respect for the human image and form beyond any reasonable limit. And intentionally disabling embryos so that they would grow without heads or brains would surely be an impermissible act of creating and sacrificing potential humans solely for the benefit of others. The genetic revolution presents important scientific and moral issues for society. We need to be concerned about how genetic information will be used by government, industry, the military, and the medical profession. We should be concerned that genetic knowledge can threaten our privacy, imperil our right to health care or a job, leave us vulnerable to loss of insurance, or even force us to know things about our future that we might not want to know. We should wonder how a knowledge of our potential child's genetic legacy will shape reproductive choices. These issues require a lot of hard thinking. Scientists and those who are interested in the ethical consequences of advances in science must strive to point public debate toward what is practical and possible as well as what is plausibly moral. Since we are currently armed with heads and brains, it behooves us to use them to decide how best to cope with the real benefits and risks of an increasing flood of genetic knowledge. [1]: /lookup/doi/10.1126/science.278.5339.798

Previous refusal of consent may not be relevant

Abstract: Over the past three decades informed consent has become an extremely important aspect of the clinical management of patients. Allowing patients to control the nature and extent of the care they are given has become an inviolable moral value. Patient autonomy takes precedence over both professional beneficence and the contrary wishes of others. Any decision to violate a patient's wishes would be condemned as intolerable paternalism at best—and manipulation, coercion, or even assault at worst. Why then does this patient's case pose a moral problem? The moral problem arises because informed consent is often not a reliable guide in the care …