Showing papers in "Hastings Center Report in 1985"

The Many Faces of Competency

Abstract: KIE: A sliding-scale model for assessing patient competency to consent to medical treatments is proposed. The least stringent standard, to be applied in the case of safe and effective treatments, assumes a valid consent if the patient is aware of what is happening and assents to the rational expectations of the physician. The second standard, applicable in the case of less certain treatments, requires that the patient understand the treatment options and have the capacity to choose or reject a treatment based on a weighing of risks and benefits. The third and most stringent standard, reserved for very dangerous treatments, bases competence to consent on an appreciation of the implications of the medical information for the patient's life and on an ability to state the reasons for the decision in terms of the medical issues and the patient's personal values.

Community: The Neglected Tradition of Public Health

Abstract: The political focus in the United States has been on individualism with minimal restrictions on property and personal conduct. Government regulation or paternalism has been accepted, however, in the area of public health. Political thought has embraced the concepts of common or group interests which must be protected and which legitimize the police power of the state. Contemporary public health problems such as fluoridation, alcoholism, the wearing of motorcycle helmets, and the discouragement of smoking are discussed in terms of constitutional rights and the collective good. Language: en

Rethinking the Morality of Animal Research

Abstract: The debate on animal research has entered a new phase, involving a reevaluation of the moral status of animals, a detailed examination of the biological and philosophical meaning of animal pain and suffering, and a closer examination of the benefits of different types of knowledge. We need a clearer understanding of the ethical issues in animal research to provide the groundwork for public policy.

The limits of the ledger in public health promotion.

Abstract: Recent efforts to support state regulation of risky behavior like cigarette smoking, alcohol consumption, driving without seatbelts and riding motorcycles without helmets have focused on economic justifications--the costs to society of the consequences of these activities. However, opponents have successfully argued that the economic burdens of regulation outweigh the social benefits. To reduce the toll on society of these behaviors, we need justification for regulation that asserts the moral primacy of health and the well-being of the community.Recent public policy debates over seatbelt and motorcycle helmet laws and taxes on alcohol and tobacco are described and evaluated. Advocates of stronger state actions in these areas are faulted for framing their justifications almost solely in economic terms, leaving their opponents able to argue that the economic burdens of regulation outweigh the social benefits. It is concluded that the justification for such regulation must include an assertion of the moral primacy of health as a social good and of the well-being of the community as a legitimate concern of public policy.

The Mistreatment of Dead Bodies

Abstract: Cadavers have a multitude of possible uses--from the harvesting of organs, to medical education, to automotive safety testing--and yet their actual utilization arouses profound aversion no matter how altruistic and beneficial the motivation. Feinberg considers the causes and effects of this cultural phenomenon and examines discussions by several moral philosophers of the conflict between offended sentiment and appeals to interest. He takes exception to arguments advanced in defense of moral sensibility and concludes that there is no unmanageable conflict between effective humanitarianism and the maintenance, under flexible control, of the essential human sentiments. Language: en

What do children owe elderly parents

Abstract: n the spring of 1983 the Reagan administration announced that states may under Medicaid legally require children to contribute to the support of their elderly parents At the time a number of states were considering or enacting just such laws The administration, one spokesman said, was not proposing anything inherently new It was simply responding to a state request for clarification of the existing Medicaid law, and wanted only to say that state statutes enforcing family responsibility laws were not in conflict with federal policy' As it turned out, the administration's initiative was a policy shift whose time had not come While a number of states flirted for a time with new family responsibility policies, only a few (Virginia, Idaho, and Mississippi, for example) actually adopted them, and even fewer seem to be enforcing them As pressing as the state Medicaid nursing home burden is, it rapidly became clear that there is little general sentiment to force children to provide financially for their elderly parents Nonetheless, Reagan's initiative was an important social and policy event and raises significant moral issues In one form or another, the idea is likely to arise again Anything that can be done to raise revenue to reduce the Medicaid burden probably will be done Three questions are thus worth considering What kind of a moral obligation do children have toward the welfare of their elderly parents? Can it be said that the changed health, longevity, and social circumstances of the elderly justify a shift in traditional moral obligations? Even if children do have some significant duties to parents, is it still legitimate to ask the state to take over much of the direct burden of care? The first question is of course an old one Each generation has had to make its own sense of the biblical injunction that we should honor our fathers and mothers It neither tells us in what "honor" consists nor how far filial obligation should be carried As a piece of practical advice, however, it once made considerable sense In most traditional and agricultural societies, parents had considerable power over the lives of their offspring Children who did not honor their parents risked not only immediate privation, but also the loss of the one inheritance that would enable them to raise and support their own families-land they could call their own

Religious Justifications for Donating Body Parts

Abstract: May discusses religious justifications for organ donation as alternatives to marketplace purchase, voluntary donation, and routine salvaging. He responds to Feinberg's proposal for a national system of salvaging and his criticism of the tendency to invest a dead body with symbolism that hampers organ donation. After exploring the implications for transplantation of the Christian Scientist, dualist, and Gnostic outlooks, May considers aspects of the Judeo-Christian tradition that influence attitudes toward organ donation and transplantation. He calls upon religious institutions to assume a leadership role in arousing conscience and in encouraging organized giving of organs.

Medical ethics the Japanese way.

Abstract: is beginning to grow, the number of people concerned with this area of study is still quite small. The following descriptions, therefore, do not portray afield of Japanese medical ethics, but illustrate particular issues in Japanese health care with ethical implications. They are drawn from my experiences as a student of medical ethics in Japan. My host institution was the Mitsubishi-Kasei Institute of Life

Thinking about the body.

Abstract: The relation between a human being and his body is a complicated question made more problematic by new technologies. Kass ponders the \"mind-body problem\" in its many aspects. He discusses the body in speech and experience, examines its unitary and bipolar properties, and comments on the results of upright posture and on the body as a source of both pride and humility. He considers the nature of human dignity and the development of sociability and culture. In comparing cultures based on their treatment of the dead, he finds that \"hyperrational\" societies demonstrate the least respect for both living and dead bodies. He concludes that modern scientific man is losing his respect for the meaning of life by his insistence on achieving autonomy through biomedical technologies.

The final, anticlimactic rule on Baby Doe.

Abstract: DHHS's rule on the care of imperiled newborns has a symbolic significance for the groups that struggled for compromise, but it will have a minimal impact on medical and moral decision making

Baby Fae: The “Anything Goes” School Of Human Experimentation

Abstract: The case of Baby Fae is likened to previous cases of high-risk xenograft experiments in which members of groups at particular risk for exploitation were sacrificed to scientific progress in violation of major precepts of the Nuremberg Code. Annas finds fault with the scientific justification for performing the experiment on an infant, the adequacy of the Institutional Review Board review, and the quality of the parents' consent. He concludes that, if current federal regulations cannot prevent such gross exploitation of the terminally ill, they must be revised. In addition, a \"national review board\" should perhaps be established to deal with complex new technologies.

DRGs: the counterrevolution in financing health care.

Abstract: KIE: The authors predict that the Diagnosis Related Group (DRG) system for prospective reimbursement of hospitals under Medicare, also used by several state Medicaid programs, will almost certainly be adopted in some version by private health insurers. Their thesis is that such a drastic alteration in health care economics will reduce access to care, compromise its quality, impede the development of new medical technologies, and accelerate the takeover of American medicine by large, for-profit corporations. Dolenc and Dougherty argue for an alternative system based on the assumption that health care is a right, not a commodity. In the interim they propose modifications in the DRG scheme to protect access to care by vulnerable groups and to subsidize non-profit hospitals by taxing for-profit ones.

Why Britain Can't Afford Informed Consent

Abstract: In the case of Mrs. Amy Sidaway, the House of Lords has rejected the “American” legal doctrine of informed consent, which is based on patients' rights, in favor of a standard based on the obligations of the reasonable physician. The British National Health Service, with centralized planning, prospective funding, and limited resources, is unlikely to provide a safe harbor for a doctrine based on individual choice in health care.

Will live organ donations no longer be justified

Abstract: Far from it. But improvements in the technology of organ transplantationparticularly the use of the antirejection drug cyclosporin-have altered the clinical picture radically. Soon, if current trends continue, it may be hard to justify using living donors. Before 1979, discussions dominated the literature comparing the poor results obtained using unrelated cadaver kidneys with success rates for intrafamily transplants, which were estimated to be about 30 percent higher. In that year, cyclosporinsteroid therapy was introduced into clinical medicine, bringing with it a striking improvement in the outlook for cadaver transplants. Medical centers that regularly use cyclosporin therapy now report one-year cadaveric graft survival of better than 75 percent. In some series one-year graft survival has run as high as 90 percent, using randomly matched organs and unrelated donors. Thus, one year after surgery, the results for cadaver and intrafamily transplants have become competitive, thereby greatly reducing the survival advantage for the latter group of patients. In light of these developments, thoughtful physicians, as well as potential recipients and donors, are reconsidering the advisability of living related donations. Such a reassessment is welcome considering the ethical questions raised by the history of transplants using living donors. The legal basis for a living donor nephrectomy was established in Massachusetts in 1954 in a decision involving

AIDS: The challenge to science and medicine.

Abstract: A comprehensive review of the AIDS phenomenon in the U.S. as of 1985 is a introducing a series of articles on the topic. It begins with an introduction to the history of AIDS and of the AIDS virus called HTLV for human T-cell lymphotropic virus. The biology of the virus is described noting several of its virulent characteristics such as the fact that it is a retrovirus and thus will be incorporated into cell genes releasing new virus particles for a lifetime; its tendency to mutate and thus be highly difficult to design a vaccine to match; and the poor performance of HTLV antibodies in inactivating the infecting virus. The review goes on to discuss the origin of AIDS and its behavior in African populations. A final section speculates on the risk of transmission of AIDs to heterosexual Americans not belonging to any of the identified high risk groups male homosexuals intravenous drug users or hemophiliacs or their sexual partners. Since the case mortality rate is 100% the only way to block the spread of AIDs is to discover a vaccine or a drug which will slow down the replication of the virus once it enters the body. There are no practical drugs envisioned for these types of treatment except for the natural interferons.

No cheers for temporary artificial hearts.

Abstract: The author continues his argument against the temporary artificial heart (\"The Phoenix heart: what we have to lose,\" Hastings Center Report 1985 Jun; 15(3): 15-16) with an account of recipient Michael Drummond's experience at the University of Arizona in August 1985. Annas faults the University's informed consent procedure and labels its consent form \"misleading, rudimentary, and confusing.\" He also questions why Drummond was assigned top priority for a human heart after he had received a temporary artificial one. Annas urges a moratorium on permanent artificial hearts because of their devastating effects on recipients, and on temporary devices because they may become permanent. He also argues that there is, as yet, no ethically acceptable way of allocating human hearts to those with artificial hearts, and that the expensive bridge-to-transplant procedure fails to increase the total number of lives saved by heart transplants.

Clinical Care and Research in AIDS

Abstract: This article addresses ethical issues associated with the acquired immunodeficiency syndrome (AIDS) particularly those relevant to patient care and clinical research. The concentration of AIDS cases in large urban areas of the US has resulted in the centralization of AIDS care at teaching hospitals. Physicians in training in such hospitals have been especially burdened by the care of AIDS patients and the ethical issues they must confront are not addressed in medical education. The need to protect the confidentiality of AIDS patients is particularly acute because AIDS affects population groups already at risk for discrimination; however this need often conflicts with the need to study and track the AIDS epidemic. Another dilemma concerns the impact of financial allocations for AIDS programs on other health services in a period of economic stringency. Many of the ethical issues that arise in AIDS care and clinical research are commonly encountered in other serious illnesses: the ethics of controlled trials the apportionment of costs of clinical research and the availability of experimental drugs to members of prepaid health plans. As experimental therapy in AIDS has progressed pressure has been exerted in favor of placebo-controlled drug trials. Not only have some investigators been unwilling to offer placebo therapy but many AIDS patients are well informed about their illness and unwilling to participate in such trials. Finally the authors offer 3 recommendations to those involved in this area. 1st it is maintained that physicians should not refuse to care for patients with AIDS out of concern for occupational contagion--a negligible risk anyway. 2nd it is stressed that the identity of AIDS patients must be carefully protected. 3rd patients with AIDS must be given equal access to expert comprehensive and sensitively administered medical care.

The MD and the DRG.

Abstract: As they struggle to maintain high-quality health care in the face of new economic limitations, physicians should not endanger their relationships with patients. But they should collectively revise the informal protocols that guide clinical decision making. C ost containment in health care poses enormous challenges for the traditional values of medicine. Health care delivery now comprises over 10 percent of the Gross National Product and

Has success spoiled hospice

Abstract: Now in its second decade in the U.S., hospice has moved from a fringe alternative led by an idealistic group of volunteers and professionals to a mainstream, industry-like approach to the care of the terminally ill. Success has brought uniformity and fiscal constraints, but the commitment to “low-tech, high-touch” care has not changed.

AIDS and the threat to public health.

Abstract: This article discusses problematic ethical issues such as sexual identity medical confidentiality civil liberties and discrimination raised by the acquired immunodeficiency syndrome (AIDS). In the absence of an effective treatment or vaccine education has been the dominant weapon against AIDS. However discomfort with public discussion of gay sex on the part of some heterosexuals and the fear on the part of many gay activists that a focus on gay sexual practices could increase homophobia have made health education around AIDS a sensitive subject. In addition the issue of confidentiality pervades all aspects of the AIDS crisis. California has taken a strong stand to protect confidentiality and individual human dignity through legislation that imposes stiff penalties for disclosure fo the results of human T-lymphotropic virus type III (HTLV-III) antibody tests and stipulates that these results cannot be used to determine eligibility for insurance or suitability for employment. The AIDS crisis has been characterized by reactions based more on fear than reason such as the exclusion of pediatric AIDS victims from schools and day care. Some have called for the isolation of AIDS victims--a measure that would be not only ineffective given the fact that the most contagious people are those who show few or no signs of AIDS but also an abrogation of the civil rights of terminally ill individuals. Ethical issues are also raised by AIDS victims who are intravenous drug abusers and already social outcasts. It is the authors opinion that the government should rethink its policy toward drug abusers so that both addiction and its association with AIDS can be dealt with as health issues. A final issue discussed is the gay bathhouse which has facilitated the sexual behavior associated with AIDS. The recent closure of such facilities raises the difficult question of when does health regulation supersede the rights of consenting adults.

Fetal Research: The State of the Question

Abstract: federal regulations for fetal research "conducted by the Department of Health and Human Services (DHHS) or funded in whole or in part by a Department grant, contract, cooperative agreement or fellowship" were constructed on the soundest ethical principles: equality of protection for all research subjects; and the benefits to individuals and society that may be realized by research activities.' Further, to resolve conflicts between these principles, the guidelines were set within a system of institutional controls with interaction between local and national

The fieldworker as watcher and witness.

Abstract: In a field like genetic counseling, a medical sociologist is not only a doctor-watcher but a witness who tries to interpret the moral conflicts that lie beneath the surface of an advancing technology.

The case against thawing unused frozen embryos.

Abstract: Whether one believes that the embryo has rights from the instant of conception, or that the embryo has no moral rights at all, the conclusion about the fate of unused frozen embryos is the same: they ought to be preserved in their frozen state until they are implanted in a woman's womb or are no longer able to survive implantation.

When procedures limit rights: from Quinlan to Conroy.

Abstract: T he New Jersey Supreme Court has concluded that there is no analytical difference between terminating artificial feeding and discontinuing a mechanical ventilator, an action it permitted in the 1976 Karen Ann Quinlan case. In Quinlan, the court wanted to get Karen off a ventilator, and devised a method designed to make physicians feel comfortable about removing the machine. However, by focusing on the physicians and their fear of liability, the Quinlan court ignored Karen's right to refuse treatment and issued an ill-defined and potentially dangerous opinion that permitted Karen's guardian, family, and physician to do almost whatever they wanted to her with legal immunity (George J. Annas, "In re Quinlan: Legal Comfort for Doctors," Hastings Center Report, June 1976, pp. 29-31). This "Catch 22" approach to treatment refusals, in which incompetent patients are given a substantive right to refuse treatment that must be procedurally exercised in such a way that it will either never be exercised, or can be exercised in a way inconsistent with their wishes, also forms the basis of the 1985 Claire Conroy decision.

Screening blood: public health and medical uncertainty.

Abstract: Use of the human T-lymphotropic virus type III (HTLV-III) antibody screening test for reducing the risk of contracting acquired immunodeficiency syndrome (AIDS) through blood transfusion has raised ethical issues regarding notification and confidentiality. It has also raised longterm questions about mass screening mandatory reporting of positive results to public health officials behavioral change and public health interventions under conditions of medical uncertainty. Initially blood banks resisted mandatory notification of antibody-positive donors on the grounds that it established a clinical relationship between donor and blood bank and also might encourage people to come to blood centers solely to get their tests results. Now that other agencies have had time to set up alternative sites for HTLV-III antibody testing blood banks will begin to inform people about their positive antibody status. Names of seropositive individuals will be kept in the American Red Cross confidential national deferral registry. Those who test positive on a single test only will not be notified and their names will not be entered in the national registry but their names will be kept in a local registry and subsequent donations will be discarded. A troubling question concerns whether to notify past recipients of blood from donors who are now seropositive. Most blood banks have adopted a policy of not notifying such recipients since it is not known whether the donor had antibodies at the time of the index donation. Because of the psychological trauma associated with notification blood centers and alternative test sites plan to offer counseling to seropositive persons. More compelling evidence of a public health threat than presently exists will be required to justify mass screening of all those at risk of contracting or spreading AIDS. Such testing would threaten the civil liberties of the persons tested.

Who Speaks for the Patient with the Locked‐In Syndrome?

Abstract: A case is presented involving a nursing home patient who suffered a stroke that left him unable to speak or move, and thus unable to communicate his wishes except through eye movement. Steffen ponders several questions related to whether this patient should be given life-prolonging treatment, including whether he is competent to give or withhold consent, how a guardian could justify a third-party consent or refusal, and whether the attending physician could write a "do not resuscitate" order without the approval of the patient's guardian. He concludes intuitively that life-sustaining therapy should not be given in view of the patient's quality of life and the burden of his illness. Franklin disagrees, contending that it is unfair to withhold life-sustaining therapy because a patient cannot communicate and that there is an increasing number of cases on record of patients with locked-in syndrome who have recovered or have learned to communicate through Morse code or computers.

Physicians and Patients in Transition

Abstract: Despite growing consumerism and skepticism about authority in the culture as a whole, most patients continue to be pliant. If there is a serious threat to physician autonomy, it is more likely to come from third-party payers and new forms of medical practice, particularly the rise of for-profit hospital chains, than from patients. Though physicians are restless, they will learn to adapt to the new conditions of practice.