Summary Principles Timely support for patients and people close to them, and effective, sensitive communication are essential. Decisions must be based on the individual patient's circumstances and reviewed regularly. Sensitive advance discussion should always be encouraged, but not forced. Information about CPR and the chances of a successful outcome needs to be realistic. Practical matters Information about CPR policies should be displayed for patients and staff. Leaflets should be available for patients and people close to them explaining about CPR, how (...) decisions are made and their involvement in decisions. Decisions about attempting CPR must be communicated effectively to relevant health professionals. In emergencies If no advance decision has been made or is known, CPR should be attempted unless: the patient has refused CPR; the patient is clearly in the terminal phase of illness; or the burdens of the treatment outweigh the benefits. Advance decision making Competent patients should be involved in discussions about attempting CPR unless they indicate that they do not want to be. Where patients lack competence to participate, people close to them can be helpful in reflecting their views. Legal issues Patients' rights under the Human Rights Act must be taken into account in decision making. Neither patients nor relatives can demand treatment which the health care team judges to be inappropriate, but all efforts will be made to accommodate wishes and preferences. In England, Wales and Northern Ireland relatives and people close to the patient are not entitled in law to take health care decisions for the patient. In Scotland, adults may appoint a health care proxy to give consent to medical treatment. Health professionals need to be aware of the law in relation to decision making for children and young people.IntroductionWhy policies are neededCardiopulmonary resuscitation can be attempted on any person whose cardiac or respiratory functions cease. Failure of these functions is part of dying and thus …. (shrink)

With the escalation of terrorism worldwide in recent years, situations arise in which the perpetration of violence and the defense of human rights come into conflict, creating serious ethical problems. The Geneva Convention provides guidelines for the medical treatment of enemy wounded and sick, as well as prisoners of war. However, there are no comparable provisions for the treatment of terrorists, who can be termed unlawful combatants or unprivileged belligerents. Two cases of severely injured terrorists are presented here to (...) illustrate the dilemmas facing the medical staff that treated them. It is suggested that international legal and bioethical guidelines are required to define the role of the physician and auxiliary medical staff vis a vis injured terrorists. There are extreme situations where the perpetration of violence and the defense of human rights come into conflict, leading to serious ethical and psychological discord. Terrorists, using violence to create fear in order to further their political objectives, might require life-saving medical care if injured during the course of their terror activities. (shrink)

That a standard of medical care must outline services that benefit the patient is relatively uncontroversial. However, one must determine how the practices outlined in a medical standard of care should benefit the patient. I will argue that practices outlined in a standard of medical care must not detract from the patient’s well-functioning and that clinicians can refuse to provide services that do. This paper, therefore, will advance the following two claims: (1) a standard (...) of medical care must not cause dysfunction, and (2) if a physician is medically rational to not provide some service which fails to meet the above condition (i.e. fails to be a standard of medical care), then she may refuse to do so. I then apply my thesis to the prescription of puberty blockers to children with gender dysphoria. (shrink)

In Britain before 1911, the vast majority of the population provided medical care for themselves and had evolved a variety of schemes that checked the power of organized medicine and encouraged a steady improvement in standards. The evidence is that at the end of the nineteenth century about 5–6 percent of the population relied on the poor law, 10–15 percent on free care from charitable institutions, 75 percent on mutual aid, and the remainder paid fees to private (...) doctors. (shrink)

Prominent among the principles put forward by Professor Bernard Williams in ‘The Idea of Equality’ were that for every difference in the way men are treated a relevant reason should be given and the proper ground of the distribution of medical care is ill health. Prominent among his conclusions was that we are confronted with an irrational state of affairs where wealth functions as a necessary condition for receiving medical care. In ‘The Idea of Equality Reconsidered’ (...) Philosophy 85–90), I argued that, on his principles alone, this conclusion though correct was one-sided. (shrink)

With the escalation of terrorism worldwide in recent years, situations arise in which the perpetration of violence and the defense of human rights come into conflict, creating serious ethical problems. The Geneva Convention provides guidelines for the medical treatment of enemy wounded and sick, as well as prisoners of war. However, there are no comparable provisions for the treatment of terrorists, who can be termed unlawful combatants or unprivileged belligerents. Two cases of severely injured terrorists are presented here to (...) illustrate the dilemmas facing the medical staff that treated them. It is suggested that international legal and bioethical guidelines are required to define the role of the physician and auxiliary medical staff vis a vis injured terrorists. There are extreme situations where the perpetration of violence and the defense of human rights come into conflict, leading to serious ethical and psychological discord. Terrorists, using violence to create fear in order to further their political objectives, might require life-saving medical care if injured during the course of their terror activities. (shrink)

U.S. politicians and policymakers have been preoccupied with how to pay for health care. Hardly any thought has been given to what should be paid for—as though health care is a commodity that needs no examination—or what health outcomes should receive priority in a just society, i.e., rationing. I present a rationing proposal, consistent with U.S. culture and traditions, that deals not with “health care,” the terminology used in the current debate, but with the more modest and (...) limited topic of medical care. Integral to this rationing proposal—which allows scope to individual choice and at the same time recognizes the interdependence of the individual and society—is a definition of a “decent minimum,” the basic package of medical treatments everyone should have access to in a just society. I apply it to a specific example, diabetes mellitus, and track it through a person's life span. (shrink)

Crowdfunding websites allow users to post a public appeal for funding for a range of activities, including adoption, travel, research, participation in sports, and many others. One common form of crowdfunding is for expenses related to medical care. Medical crowdfunding appeals serve as a means of addressing gaps in medical and employment insurance, both in countries without universal health insurance, like the United States, and countries with universal coverage limited to essential medical needs, like Canada. (...) For example, as of 2012, the website Gofundme had been used to raise a total of 8.8 million dollars for seventy-six hundred campaigns, the majority of which were health related. This money can make an important difference in the lives of crowdfunding users, as the costs of unexpected or uninsured medical needs can be staggering. In this article, I offer an overview of the benefits of medical crowdfunding websites and the ethical concerns they raise. I argue that medical crowdfunding is a symptom and cause of, rather than a solution to, health system injustices and that policy-makers should work to address the injustices motivating the use of crowdfunding sites for essential medical services. Despite the sites’ ethical problems, individual users and donors need not refrain from using them, but they bear a political responsibility to address the inequities encouraged by these sites. I conclude by suggesting some responses to these concerns and future directions for research. (shrink)

The aging of the population presents modern Western society with a variety of different challenges, especially in the areas of health and medicine. On the one hand, there is the demand of the elderly patients to receive medical treatments that are supposed to improve or preserve the existing quality of life and to prevent the extension of a life without quality, with suffering and pain. On the other hand, aging is accompanied by the appearance and exacerbation of chronic illnesses, (...) reduces the treatment benefits of medical activities and increases the risks of irreversible physical dependence. Furthermore, the lack of consensus among the physicians regarding the willingness of treatment and the proper timing of the treatment of the elderly – pose questions about the quality of the treatment for the elderly. Thus, in the opinion of different care-providers and in comparison to other age groups in modern Western society, the elderly do not enjoy the treatment advantages of medical activities proven in the treatment of other age groups in society. (shrink)

Challenges in Medical Care Edited by Andrew Grubb School of Law and Centre of Medical Law and Ethics, King’s College, London, UK The sixth volume in the series of King’s College Studies takes a reflective view of medical law and ethics, the health care system and challenges raised by modern technology. A distinguished team of authors returns to problems and controversies that have long challenged medical law and ethics, and shows how new issues are (...) constantly arising as a result of developments in medical care. Topics such as the legal status of the frozen human embryo, medical accountability and the future of the National Health Service are discussed. The need for responsibility, accountability and respect for individual human rights forms a strong linking theme throughout the book. This thought-provoking collection constitutes a useful and informative reference source which will be of value to a wide range of professionals and students including doctors, nurses, lawyers, philosophers and medical sociologists. (shrink)

Outcomes from cardiopulmonary resuscitation (CPR) remain distressingly poor. Overuse of CPR is attributable to unrealistic expectations, unintended consequences of existing policies and failure to honour patient refusal of CPR. We analyzed the CPR outcomes literature using the bioethical principles of beneficence, non-maleficence, autonomy and justice and developed a proposal for selective use of CPR. Beneficence supports use of CPR when most effective. Non-maleficence argues against performing CPR when the outcomes are harmful or usage inappropriate. Additionally, policies which usurp good clinical (...) judgment and moral responsibility, thereby contributing to inappropriate CPR usage, should be considered maleficent. Autonomy restricts CPR use when refused but cannot create a right to CPR. Justice requires that we define which medical interventions contribute sufficiently to health and happiness that they should be made universally available. This ordering is necessary whether one believes in the utilitarian standard or wishes medical care to be universally available on fairness grounds. Low-yield CPR fails justice criteria. Cardiopulmonary resuscitation should be performed when justified by the extensive outcomes literature; not performed when not desired by the patient or not indicated; and performed infrequently when relatively contraindicated. (shrink)

Military doctors and nurses, working neither as pure soldiers nor as merely doctors or nurses, may face a ‘role conflict between the clinical professional duties to a patient and obligations, express or implied, real or perceived, to the interests of a third party such as an employer, an insurer, the state, or in this context, military command’. This conflict is commonly called dual loyalty. This chapter gives an overview of the military and the medical ethic and of the resulting (...) dual loyalty problem for medical personnel working in the military. It considers how dual loyalties relate to being a professional, something medical personnel are the paradigmatic examples of, but also something military personnel claim to be. Against that background, the chapter elaborates on the medical rules of eligibility used in Afghanistan, and on the policies concerning military involvement in local healthcare, to see what the existing rules and policies are, and whose interests they serve. (shrink)

The articles in this issue explore a number of difficult choices in medical care and research. They investigate ethical complexity in a range of decisions faced by policymakers and clinicians, and offer new evidence or normative approaches for navigating this complexity. In this issue’s feature article, Ford and colleagues engage with an ethical challenge faced by policymakers in relation to health research: should free text data contained in medical records be shared for research purposes?1 While some types (...) of data from electronic medical records are used widely in health research, privacy concerns have limited the use of free text data specifically. Ford and colleagues highlight the richness of the clinical information in free text and its centrality to some areas of healthcare such as mental health and primary care. In their view, while text analytic technology is developing rapidly, ‘policy makers routinely judge that the risk of re-identifying patients from text data is too high for these data uses’. Their citizens’ jury study in the UK found that participants were largely in favour of medical free text data being shared outside the NHS for research using an opt-out model: ‘the majority of jurors believed the benefits of sharing data for research outweighed the privacy risks’. In their commentary on this research, Largent and Morain raise some important issues about policymakers’ use of empirical findings …. (shrink)

The aim of this discussion is practical; otherwise it largely repeats some very general observations, chiefly historical and philosophical. I boast no expertise in anything specifically medical, to do with either medical care or medical administration. My concern is with the system of medicine and with the ethical and social issues that it involves. Applied philosophy is a still uncharted territory. Philosophers traditionally focus more on justifying accepted solutions than on seeking new solutions to urgent or (...) interesting problems: their staple problems are those of justification. Thus, they spend less time discussing scientific problems and difficulties, and more time discussing the justification of the claims that we know. They habitually choose the simplest and most unproblematic claims for knowledge, and then try to substantiate them... (shrink)

The healthcare systems of the United States and United Kingdom are vastly different. The former relies primarily on private sector incentives and market forces to allocate medical care services, while the latter is a centrally planned system funded almost entirely by the public sector. Therefore, each nation represents divergent views on the relative efficacy of the market or government in achieving social objectives in the area of medical care policy. Since its inception in 1948, the National (...) Health Services of the United Kingdom has consistently emphasized equity in the allocation of medical services. It has done so by creating a system whereby services are universally free of charge at the point of entry. Conversely, the United States has relied upon the evolution of a perplexing array of public and private sector insurance schemes centered more around consumer choice than equity in allocation. (shrink)

This article focuses on rationing of expensive medical care in the Czech Republic. It distinguishes between political and clinical decision levels and reviews the debate in the Western literature on explicit and implicit rules. The contemporary situation of the Czech health care system is considered from this perspective. Rationing reoccurred in the mid 90s after the shift in health care financing from fee-for-service to prospective budgets. The lack of explicit rules is obvious. Implicit forms of rationing, (...) done by physicians at the clinical level prevail, implying uncontrolled power of the medical profession and lacking transparency for ethical considerations of equity to access. It seems to be acceptable for physicians to play the role of allocators, probably because of their experience with rationing during the socialist period. Traditional rationing stereotypes from the previous regime seem to persist despite the health care system transformation during the 90s. (shrink)

Acid attacks on women are increasing at alarming rates in Bangladesh, but the government has failed to provide medical care to the victims. Easily available sulfuric acid, which can mutilate a human face in moments, has emerged as a weapon used to disfigure a woman’s body. By the mid-1990s, activists had documented acid attacks, and urban protests were followed by demands for better medical care. I show how the interaction between local and international-level civil society organizations (...) made international resources available to local feminist groups engaged in domestic social struggles and helped to improve medical care for acid victims of Bangladesh. (shrink)

Poor quality medical care is sometimes attributed to physicians’ unwillingness to act on evidence about what works best. Evidence-based performance standards (EBPSs) are one response to this problem, and they are increasingly employed by health care regulators and payers. Evidence in this instance is judged according to the precepts of evidence-based medicine (EBM); it is probabilistic, and the randomized controlled trial (RCT) is the gold standard. This means that EBPSs suffer all the infirmities of EBM generally—well rehearsed (...) problems with the external validity of research findings as well as the inferential leap from study results in the aggregate to individual patient care. These theoretical weaknesses promise to have a practical impact on the care of patients. To avoid this, EBPSs should be understood as guidelines indicative of average effectiveness rather than standards to be applied in every case. (shrink)

In clinical research there is a tension between the role of a doctor, who must serve the best interests of the patient, and the role of the researcher, who must produce knowledge that may not have any immediate benefits for the research participant. This tension is exacerbated in HIV research in low and middle income countries, which frequently uncovers comorbidities other than the condition under study. Some bioethicists argue that as the goals of medicine and those of research are distinct, (...) it is a mistake for researchers to assume therapeutic responsibilities while engaging in research. Others propose that there is a duty of care, but disagree as to how this is limited and specified. In this qualitative study, principal investigators from HIV prevention trials discuss their experience of providing medical benefits to participants within the context of conducting research into HIV biomedical prevention technologies. They describe the limitations imposed at times by funders and at times by infrastructure constraints, and canvass the importance of ancillary care provision and capacity building in trial communities. The views of the principal investigators are compatible with the perspective that there is a duty of care, limited by the nature of the research, the depth of the relationship between research and participant, and the capacity of the research site. The therapeutic orientation in HIV prevention trial appears to be indivisible from competent research practise by making concrete and appropriate benefits available to trial participants and their communities that support rather than compete with local infrastructure. (shrink)

: This paper argues that three salient corrupt practices that mark contemporary Chinese health care, namely the over-prescription of indicated drugs, the prescription of more expensive forms of medication and more expensive diagnostic work-ups than needed, and illegal cash payments to physicians—i.e., red packages—result not from the introduction of the market to China, but from two clusters of circumstances. First, there has been a loss of the Confucian appreciation of the proper role of financial reward for good health (...) class='Hi'>care. Second, misguided governmental policies have distorted the behavior of physicians and hospitals. The distorting policies include (1) setting very low salaries for physicians, (2) providing bonuses to physicians and profits to hospitals from the excessive prescription of drugs and the use of more expensive drugs and unnecessary expensive diagnostic procedures, and (3) prohibiting payments by patients to physicians for higher quality care. The latter problem is complicated by policies that do not allow the use of governmental insurance and funds from medical savings accounts in private hospitals as well as other policies that fail to create a level playing field for both private and government hospitals. The corrupt practices currently characterizing Chinese health care will require not only abolishing the distorting governmental policies but also drawing on Confucian moral resources to establish a rightly directed appreciation of the proper place of financial reward in the practice of medicine. (shrink)

As costs decline and technology inevitably improves, current trends suggest that artificial intelligence (AI) and a variety of "carebots" will increasingly be adopted in medical care. Medical ethicists have long expressed concerns that such technologies remove the human element from medicine, resulting in dehumanization and depersonalized care. However, we argue that where shame presents a barrier to medical care, it is sometimes ethically permissible and even desirable to deploy AI/carebots because (i) dehumanization in medicine (...) is not always morally wrong, and (ii) dehumanization can sometimes better promote and protect important medical values. Shame is often a consequence of the human-to-human element of medical care and can prevent patients from seeking treatment and from disclosing important information to their healthcare provider. Conditions and treatments that are shame-inducing offer opportunities for introducing AI/carebots in a manner that removes the human element of medicine but does so ethically. We outline numerous examples of shame-inducing interactions and how they are overcome by implementing existing and expected developments of AI/carebot technology that remove the human element from care. (shrink)

BackgroundIn gender-affirming medical care (GAMC), ethical challenges in decision-making are ubiquitous. These challenges are becoming more pressing due to exponentially increasing referrals, politico-legal contestation, and divergent normative views regarding decisional roles and models. Little is known, however, about what ethical challenges related to decision-making healthcare professionals (HCPs) themselves face in their daily work in GAMC and how these relate to, for example, the subjective nature of Gender Incongruence (GI), the multidisciplinary character of GAMC and the role HCPs play (...) in assessing GI and eligibility for interventions. Given the relevance and urgency of these questions, we conducted a qualitative study among HCPs providing GAMC to transgender adults in the Netherlands.MethodsIn this qualitative research, we conducted 11 semi-structured interviews between May 2020 and February 2021 with HCPs (six mental health professionals, two HCPs in endocrinology, two in plastic surgery, and one in nursing) working in two distinct GAMC settings. We purposively sampled for professional background and years of experience in GAMC. We analyzed our interview data using thematic analysis. As some respondents were more inclined to speak about what should or ought to be done to arrive at good or right decision-making, we identified both ethical challenges and norms. Furthermore, in our analysis, we differentiated between respondents’ explicit and implicit ethical challenges and norms and ascertained the specific context in which these challenges emerged.ResultsRespondents’ ethical challenges and norms centered on (1) dividing and defining decisional roles and bounds, (2) negotiating decision-making in a (multidisciplinary) team, and (3) navigating various decision-making temporalities. These themes arose in the context of uncertainties regarding (1) GAMC’s guidelines, evidence, and outcomes, as well as (2) the boundaries and assessment of GI.ConclusionsThis interview study provides detailed empirical insight into both the explicit and implicit ethical challenges that HCPs experience and their ethical norms regarding decision-making. It also describes how uncertainties and (implicit) normativities concerning GAMC and GI pre-structure the moral environment in which these challenges and norms manifest. We provide normative reflections and recommendations on handling these ethical challenges in a way that is sensitive to the context in which they arise. (shrink)

It probably should not be surprising, in this time of soaring medical costs and proliferating technology, that an intense debate has arisen over the concept of medical futility. Should doctors be doing all the things they are doing? In particular, should they be attempting treatments that have little likelihood of achieving the goals of medicine? What are the goals of medicine? Can we agree when medical treatment fails to achieve such goals? What should the physician do and (...) not do under such circumstances? Exploring these issues has forced us to revisit the doctor-patient relationship and the relationship of the medical profession to society in a most fundamental way. Medical futility has both a quantitative and qualitative component. I maintain that medical futility is the unacceptable likelihood of achieving an effect that the patient has the capacity to appreciate as a benefit. Both emphasized terms are important. A patient is neither a collection of organs nor merely an individual with desires. Rather, a patient (from the word to suffer ) is a person who seeks the healing (meaning to make whole ) powers of the physician. The relationship between the two is central to the healing process and the goals of medicine. Medicine today has the capacity to achieve a multitude of effects, raising and lowering blood pressure, speeding, slowing, and even removing and replacing the heart, to name but a minuscule few. But none of these effects is a benefit unless the patient has at the very least the capacity to appreciate it. Sadly, in the futility debate wherein some critics have failed or refused to define medical futility an important area of medicine has in large part been neglected, not only in treatment decisions at the bedside, but in public discussions—comfort care—the physician’s obligation to alleviate suffering, enhance well being and support the dignity of the patient in the last few days of life. (shrink)

In the research ethics literature, there is strong disagreement about the ethical acceptability of placebo-controlled trials, particularly when a tested therapy aims to alleviate a condition for which standard treatment exists. Recently, this disagreement has given rise to debate over the moral appropriateness of the principle of clinical equipoise for medical research. Underlying these debates are two fundamentally different visions of the moral obligations that investigators owe their subjects.Some commentators and ethics documents claim that physicians, whether acting as (...) class='Hi'>care givers or researchers, have the same duty of beneficence towards their patients and subjects: namely, that they must provide optimal medical care. In discussing placebo surgery in research on refractory Parkinson's disease, Peter Clark succinctly states this view: “The researcher has an ethical responsibility to act in the best interest of subjects.”. (shrink)

Providing health care in the most cost-effective way has become a priority in recent years. This book tackles the important issue of the potential conflict between economic expediency and the welfare of individual patients. Contributors examine different attitudes to this complex problem, along with a variety of legal and historical perspectives. The book addresses particular aspects of health care, such as medical expert systems, general practice, medical education, and clinical decision-making where the direct involvement of doctors (...) in allocating scarce and expensive resources is perhaps most obvious. (shrink)

Patients and family members (N = 671) were surveyed in five Mid-Atlantic U.S. hospitals to ascertain the number and kinds of ethical concerns they are presently experiencing or have previously experienced while being sick or receiving medical care. Seventy percent of participants had at least one (range 0–14) type of ethical concern or question. The most commonly experienced concerns pertained to being unsure how to plan ahead or complete an advance directive (29.4%), being unsure whether someone in the (...) family was able to make their own decisions (29.2%), deciding about limiting life-sustaining treatments (28.6%), wondering about disclosing personal medical information to others in the family (26.4%) and not being sure whether to undergo treatment because of cost (26.2%). Most were interested to some degree in getting help from ethics consultants in the future (76.6%). Given this prevalence, common concerns might usefully be addressed systematically, rather than exclusively on a case-by-case basis. (shrink)

This book is a collection of papers presented at an interdisciplinary workshop at the Calgary Institute for the Humanities in May 1980. The three broad issues covered are: the physician-patient relationship, the allocation of responsibility among doctors and nurses, and the political and social framework of the health care system. The first set of essays is concerned with the moral and legal aspects of the physician-patient relationship. The link between knowledge and power is examined as well as the moral (...) dilemmas posed by medical technology. These initial essays would alone justify this publ. (shrink)