Recently, the discussion regarding the physicians’ “Right of Conscience” has been on the rise. This issue is often confined to the “reproductive health” arena within the political context. The recent dispute of the Bush-Obama administrations regarding the legal protections of health workers who refuse to provide care that violates their personal beliefs is an example of the political aspects of this dispute. The involvement of the political system automatically shifts the discussion regarding physicians’ ROC into the narrow area (...) of “reproductive health laws.” Indeed, the immediate association that comes to mind when thinking about the practical implications of this dispute is related to the reproductive health arena. This is partly because of the historical context of the first “conscience clauses,” initially enacted by Congress and state legislatures in the mid-1970s; in fact, most of these clauses provided specific exemptions for abortion and few exempted sterilization as well. (shrink)

How do we balance the rights of aging physicians against the right of the public to competent health care? This version of a classic public health ethics dilemma is here now and likely to increase as the population ages. Peer review has long been the standard mechanism for assessing physician competence, but it is subjective and too easily subverted. New options are needed, both in medicine and throughout the professions, but they are challenging to implement. Physicians have (...) an ethical obligation to protect the health of the public by acknowledging, assessing, and addressing the cognitive effects of aging on medical competence. (shrink)

INTRODUCTION[|]The practice of medicine has evolved from old approach, in which all decisions for the patient are taken by physician, to a new approach, which includes patients to the medical decision-making process and endorses informed consent of the patients. In addition to healthcare professionals and patients, parents or legal representatives are stakeholders in the informed consent process of children. The knowledge and attitudes of physicians and medical school students about the informed consent period in children are important for the (...) effectiveness of the medical intervention and the biopsychosocial development of children. In this study, it was aimed to understand involvement of medical students and physicians in the informed consent process of children and their level of knowledge on children's rights and their attitudes in daily clinical practice.[¤]METHODS[|]The study is a descriptive study and n = 150 participants, who were randomly selected from senior medical school students working in medical school campus or university hospital and physicians serving pediatric patients, were included to this study. Questionnaires were applied for the measurement of participants' socio-demographic characteristics, education on pediatric patient rights, and legal provisions. The data were evaluated using SPSS 20.00 software.[¤]RESULTS[|]Of participants, 62% (n = 93) were phase 6 medical students, while 29.33% (n = 44) were resident physicians and the rest were faculty members (8.67%; n = 13). The proportion of physicians, who didn't received training on child rights, was 80.7% (n = 46) and statistically significantly higher than medical students (49.45%; n = 45) (p <0.001). However, participants who were not educated about the children's rights stated with higher ratio (44.83%; n=65), that informed consent should be obtained before medical intervention from individuals under 18 years of age, when they are compared to the the participants who received education (20.69%; n=30) (p = 0,019). The majority of participants (59.5%; n = 88) find the intervention in individuals under the age of 18 years in emergencies without consent of legal representatives ethically and legally appropriate (p <0.001). The participants believe that it is ethically and legally appropriate to conduct an intervention on an individual under the age of 18 years without the legal representative (36. 7%; n=54) (p <0.001).[¤]DISCUSSION AND CONCLUSION[|]This study compared the levels of knowledge and attitudes of participants, who were previously trained in or didn't received any training about children's rights and informed consent of children. However, the quality of the training of the participants on children's rights, was not questioned. This study showed that education on children's rights does not significantly increase the level of legal knowledge on children's rights. Having well-designed a subject focused on this theme in medical deontology and ethics education can increase the knowledge levels and improve the attitudes of medical students. This study sheds light on the issues that need to be focused in the medical faculties and the trainings of physicians and showed lack of information and need for development of attitudes regarding children's rights and informed consent in children.[¤]. (shrink)

The author examines the ethical underpinnings of the Professional Standard Review Organizations. Four normative problems are explored in order of their importance: the problem of bureaucracy incapable of responding sensitively to individual cases; the problem of cost consciousness overcoming the commitment to quality; the problem of commitment to highest quality interfering with other social values and goals; and the problem of value judgments being made by professionals rather than patients whose rights and interests are most directly at stake. Though (...) physicians may indeed be able to balance qualitative and cost considerations with prudence, they, nevertheless, approach medical problems with their own value system. Deciding between marginal health care and alternative courses with a given amount of funds involves subtle value judgments that will vary depending on the value systems of the decision-makers. Because of their unique composition, PSROs cannot adequately reflect the social consensus about what constitutes a reasonable limit to health care. (shrink)

Background Since the enactment of the euthanasia law in the Netherlands, there has been a lively public debate on assisted dying that may influence the way patients talk about euthanasia and physician-assisted suicide with their physicians and the way physicians experience the practice of EAS. Aim To show what developments physicians see in practice and how they perceive the influence of the public debate on the practice of EAS. Methods We conducted a secondary analysis of in-depth interviews (...) with 28 Dutch physicians who had experience with a complex case of EAS. Respondents were recruited both by the network of physicians working for SCEN as well as via a national questionnaire, wherein participating physicians could indicate their willingness to be interviewed. Results Three themes came up in analysing the interviews. First, the interviewed physicians experienced a change in what patients would expect from them: from a role as an involved caregiver to being the mere performer of EAS. Second, interviewees said that requests for EAS based on non-medical reasons came up more frequently and wondered if EAS was the right solution for these requests. Last, respondents had the impression that the standards of EAS are shifting and that the boundaries of the EAS regulation were stretched. Conclusions The perceived developments could make physicians less willing to consider a request for EAS. Our results also raise questions about the role of physicians and of EAS in society. (shrink)

A physician’s long-established right to refuse to provide a requested service based on his or her moral beliefs is being challenged. Some authors suggest that physicians should not be licensed if they are unwilling to provide all legal services. Others would grant them the right to refuse, but require them to refer to a willing professional. What are the limits of a physician’s right to refuse? When such a right is claimed on moral grounds, what residual obligations does the (...) physician have to the patient? How should the profession (or society) decide when a moral claim to a right to refuse is justified? (shrink)

``What Does a Right to Physician-Assisted Suicide (PAS) Legallyentail?''''Much of the bioethics literature focuses on the morality ofPAS but ignores the legal implications of the conclusions thereby wrought. Specifically, what does a legal right toPAS entail both on the part of the physician and the patient? Iargue that we must begin by distinguishing a right to PAS qua``external'''' to a particular physician-patient relationship from a right to PAS qua ``internal'''' to a particular physician-patientrelationship. The former constitutes a negative claim right (...) inrem that prohibits outside interference with the exercise of aright to PAS while the latter can provide the patient witha positive claim right in personam to obligatory assistancefrom his physician. Importantly, I argue that the creation of sucha patient right, however, originates with the physician who may exercise an unqualified right of first refusal prior to promisingto help her patient commit suicide. In doing so, I hope to establishthat explicit physician promises of assistance in dying shouldbecome legally binding. As such, current PAS law in both theNetherlands and Oregon is in need of substantive modification. (shrink)

Many bioethicists have recently shifted from using “physician-assisted suicide” (PAS) to “medical aid-in-dying” (MAID) to refer to the act of voluntarily hastening one’s death with the assistance of a medical provider. This shift was made to obscure the practice’s connection to “suicide.” However, as the charge of “suicide” is fundamental to arguments against the practice, “MAID” can only be used by its proponents. The result has been the fragmentation of the bioethical debate. By highlighting the role of human agency—as opposed (...) to natural processes—in causing death, the term “PAS” makes it easier both to perceive potential risks to vulnerable populations and to affirm suicide as a potentially autonomous choice. As such, “PAS” thus more transparently expresses the arguments of both supporters and opponents of the “right to die,” while avoiding the unnecessary stigmatization of suicide and suicidal people which is a result of the usage of “MAID.”. (shrink)

I argue that the concept ‘physician-assisted suicide’ covers two procedures that should be distinguished: giving someone access to humane means to end his own life, and taking co-responsibility for the safe and effective execution of that plan. In the first section I explain the distinction, in the following sections I show why it is important. To begin with I argue that we should expect the laws that permit these two kinds of ‘assistance’ to be different in their justificatory structure. Laws (...) that permit giving access only presuppose that the right to self-determination implies a right to suicide, but laws that permit doctors to take co-responsibility may have to appeal to a principle of mercy or beneficence. Actually this difference in justificatory structure can to some extent be found in existing regulatory systems, though far from consistently. Finally I argue that if one recognizes a right to suicide, as Oregon and other American states implicitly do, and as the European Court of Human Rights has recently done explicitly, one is committed to permit the first kind of ‘assistance’ under some conditions. (shrink)

BackgroundAlthough the Covid-19 epidemic challenged existing medical care norms and practices, it was no excuse for unlawful conduct. On the contrary, legal compliance proved essential in fighting the pandemic. Within the European legal framework for the pandemic, patients were still entitled to be treated equally, by a specialized physician, with the possibility of seeking a second medical opinion, in a confidential setting, following prior and informed consent. This study examines physicians’ practices regarding patients’ rights during the Covid-19 pandemic (...) and the effects of age, experience, and specialty on physicians’ behavior and preferences. Additionally, it explores the nexus of malpractice complaints, malpractice fear, and legal compliance.MethodsA cross-sectional study was conducted on a convenience sample of attending physicians and general practitioners to assess compliance with patients’ rights regulations. Respondents were physicians practicing in private and public settings in Southwestern Romania from July 2021 to May 2022.Results396 attending physicians and 109 general practitioners participated in the research. Attending physicians acknowledged patients’ rights in 55.7% of statements, while general practitioners showed a slightly higher level of compliance at 59.9%. Emergency and Anesthesia and Intensive Care physicians showed the lowest compliance. There were no significant behavioral differences based on physicians’ age, years in practice, work sector, or location. However, when faced with the question of prioritizing treatment for patients with similar medical conditions, 46.2% of attending physicians reported favoring the younger patients. This preference was common among physicians under 39. Additionally, over half of the attending physicians reported working outside their area of expertise due to staff shortages. Malpractice fear was high among physicians, although unrelated to patients’ claims, legal compliance, or working outside the scope of practice. It resulted in pressure and behavioral changes.ConclusionAdherence to patients’ rights was low during the Covid-19 pandemic. Physicians could benefit from educational and administrative support to ensure better legal compliance. Further research is needed to determine if this behavior persists beyond the pandemic context. (shrink)

Background The aim of this study was to investigate whether physicians who felt strongly for or against a treatment, in this case a moderately life prolonging non-curative cancer treatment, differed in their estimation of medical indication for this treatment as compared to physicians who had no such sentiment. A further aim was to investigate how the notion of medical indication was conceptualised. Methods A random sample of GPs, oncologists and pulmonologists comprised the study group. Respondents were randomised to (...) receive either version of a case presentation; in one version, the patient had smoked and in the other version she had never smoked. The physicians were labelled value-neutral and value-influenced on the basis of their attitude towards the treatment. Results In the ‘value-influenced’ group, there was a significant difference in the estimation of medical indication for treatment depending upon whether the patient had smoked or never smoked ). There was no such difference in the ‘value-neutral’ group. Conclusion This study shows that compared to value-neutral physicians, value-influenced physicians are more likely to base decisions of medical indication on medically irrelevant factors. Moreover, medical indication is used in an ambiguous manner. Hence, we recommend that the usage of ‘medical indication’ be disciplined. (shrink)

Rawls’s theory of justice is capable of providing an important contribution to the question of physician-assisted suicide (PAS). PAS should be guaranteed as a right to make decisions in accordance with the conception of the good the individual formulates as a rational being. This defense is supported, therefore, by a Kantian premise. But it is also possible to oppose this kind of proposal by relying on differentaspects of Kant’s theory, i.e. on some variant of the famous argument against suicide based (...) on the means/end formulation of the categorical imperative. In this paper, I try to show that these attempts are not well founded, and that the Rawlsian appeal to the Kantian tradition divulges better perspectives. I also try to add considerations inspired by contextualist epistemology to the Rawlsian appeal to the burdens ofjudgment. (shrink)

Uncertainty regarding potential disciplinary action may give physicians pause when considering whether to accept a chronic pain patient or how to treat a patient who may require long-term or high doses of opioids. Surveys have shown that physicians fear potential disciplinary acrion for prescribing controlled substances and that physicians will, in some cases, inadequately prescribe opioids due to fear of regulatory scrutiny. Prescribing opioids for long-term pain management, particularly noncancer pain management, has been controversial; and boards have (...) investigated and, in some cases, disciplined physicians for such prescribing. While in virtually all of these cases the disciplinary actions were successfully appealed, news of the success was not often as well-publicized as news of the disciplinary actions, leaving some physicians confused about their potential liability when prescribing opioids for pain. The confusion has perhaps increased as a result of two relatively recent cases, one where a physician was successfully disciplined by a state medical board for undertreatment of his patients’ pain, and another where the physician was successfully sued for inadequate pain treatment. (shrink)

Objective Although patients exercise greater autonomy than in the past, and shared decision making is promoted as the preferred model for doctor-patient engagement, tensions still exist in clinical practice about the primary locus of decision-making authority for complex, scarce, and resource-intensive medical therapies: patients and their surrogates, or physicians. We assessed physicians’ attitudes toward decisional authority for adult venoarterial extracorporeal membrane oxygenation (VA-ECMO), hypothesizing they would favor a medical locus. Design, Setting, Participants A survey of resident/fellow physicians (...) and internal medicine attendings at an academic medical center, May to August 2013. Measurements We used a 24-item, internet-based survey assessing physician-respondents’ demographic characteristics, knowledge, and attitudes regarding decisional authority for adult VA-ECMO. Qualitative narratives were also collected. Main Results A total of 179 physicians completed the survey (15 percent response rate); 48 percent attendings and 52 percent residents/ fellows. Only 32 percent of the respondents indicated that a surrogate’s consent should be required to discontinue VA-ECMO; 56 percent felt that physicians should have the right to discontinue VA-ECMO over a surrogate’s objection. Those who self-reported as “knowledgeable” about VA-ECMO, compared to those who did not, more frequently replied that there should not be presumed consent for VA-ECMO (47.6 percent versus 33.3 percent, p = 0.007), that physicians should have the right to discontinue VAECMO over a surrogate’s objection (76.2 percent versus 50 percent, p = 0.02) and that, given its cost, the use of VA-ECMO should be restricted (81.0 percent versus 54.4 percent, p = 0.005). Conclusions Surveyed physicians, especially those who self-reported as knowledgeable about VA-ECMO and/or were specialists in pulmonary/ critical care, favored a medical locus of decisional authority for VA-ECMO. VA-ECMO is complex, and the data may (1) reflect physicians’ hesitance to cede authority to presumably less knowledgeable patients and surrogates, (2) stem from a stewardship of resources perspective, and/or (3) point to practical efforts to avoid futility and utility disputes. Whether these results indicate a more widespread reversion to paternalism or a more circumscribed usurping of decisional authority occasioned by VA-ECMO necessitates further study. (shrink)

Physicians, so it will be argued have by virtue of their profession a weightier obligation than patients to disclose their HIV infection, and also have a duty to refrain from performing exposure-prone invasive procedures. This argument supports both the AMA and CDC guidelines on HIV infected health care workers (HCWS), while undermining the recommendations against disclosure suggested by the National Commission on AIDS (NCA). The argument is divided into three parts. First, a distinction is made between entrenched and fuzzy (...) roles. Second, the physician-patient relationship is described as essentially fiduciary rather than businesslike or merely contractual. Third, the conflict between patients' and physicians' right to know is portrayed as one between patients' and physicians' right to life. Last, given the the probability of infection from seropositive patients to seronegative physicians, and, conversely, is roughly the same, it is recommended as a fair social policy that whenever an invasive procedure occurs, both physicians and patients have a duty to disclose any serious infection that may jeopardize their lives. (shrink)

Epicurus wrote that death cannot be bad for a person who dies, since when someone dies they no longer exist to be the subject of harm. But his conclusion also applies in the converse: Death cannot be good for someone, since after their death they will not exist to be the subject of benefit. This conclusion is troubling when it is brought to bear on the question of physician assisted suicide. If Epicurus is right, as I think he is, then (...) it means that even when someone is dying of a long and painful illness, we cannot say that they would be better off dead. I defend this conclusion by first presenting Epicurus’s argument, and defending it against some of its more important contemporary critics. I then re-examine the conclusion that someone cannot be better off dead by looking at the issue of mercy killing and euthanasia. Drawing on the work of philosophers who examine the ethics of animal euthanasia, I argue that killing someone who is suffering severe agony can be good, but it cannot be good for the person who suffers – it is just good in itself. This, I think, is why we have the intuitions that we do around physician assisted suicide: we are mistaken about the idea that someone can be better off dead, but we can be correct in thinking that sometimes someone’s death is good. (shrink)

OBJECTIVES: To study and report the attitudes and practices of physicians in a former Soviet republic regarding issues pertaining to patients' rights, physician negligence and the acceptance of gratuities from patients. DESIGN: Survey questionnaire administered to physicians in 1991 at the time of the Soviet breakup. SETTING: Estonia, formerly a Soviet republic, now an independent state. SURVEY SAMPLE: A stratified, random sample of 1,000 physicians, representing approximately 20 per cent of practicing physicians under the age (...) of 65. RESULTS: Most physicians shared information with patients about treatment risks and alternatives, with the exception of cancer patients: only a third of physicians tell the patient when cancer is suspected. Current practice at the time of the survey left patients few options when physician negligence occurred; most physicians feel that under a reformed system physician negligence should be handled within the local facility rather than by the government. It was common practice for physicians to receive gifts, tips, or preferential access to scarce consumer goods from their patients. Responses varied somewhat by facility and physician nationality. CONCLUSION: The ethics of Soviet medical practice were different in a number of ways from generally accepted norms in Western countries. Physicians' attitudes about the need for ethical reform suggest that there will be movement in Estonia towards a system of medical ethics that more closely approximates those in the West. (shrink)

Advance health care directives and informed consent remain the cornerstones of patients' right to self-determination regarding medical care and preferences at the end-of-life. However, the effectiveness and clinical applicability of advance health care directives to decision-making on the use of life support systems at the end-of-life is questionable. The Uniform Anatomical Gift Act (UAGA) has been revised in 2006 to permit the use of life support systems at or near death for the purpose of maximizing procurement opportunities of organs medically (...) suitable for transplantation. Some states have enacted the Revised UAGA (2006) and a few of those have included amendments while attempting to preserve the uniformity of the revised Act. Other states have introduced the Revised UAGA (2006) for legislation and remaining states are likely to follow soon. (shrink)

This essay sets down three directives for conscientiously objecting clinicians—physicians, particularly obstetrician/gynecologists, trained in NaProTechnology by the Pope Paul VI Institute and Creighton University School of Medicine and any medical professionals who share their natural law vision of reproductive health care—to protect their right to well-formed conscientious objection in reproductive medicine. Directive one: understand the nature of a well-formed conscience and its rightful exercise. Directive two: fulfill all reasonable American College of Obstetricians and Gynecologists’ requirements for conscientious refusal. Directive (...) three: execute a political strategy to protect health-care conscience rights. (shrink)

This paper examines whether physician-assisted suicide is morally permissible, and whether it should be legalised in the sense that those seeking or performing such procedure will be immune from prosecution. The issues of moral and legal permissibility1 are closely connected. One way to argue for the permissibility of PAS is grounded in the argument that a patient has the right to refuse life-saving equipment, or to have it withdrawn,2 and then to further argue that there is no relevant distinction between (...) refusal/withdrawal and PAS, if the patient consents. This is essentially the argument raised in “The Philosophers’ Brief ”, filed by six distinguished philosophers. However, this argument has been soundly criticised. Frances Kamm points out that the general claim on which Dworkin et al. rely—that there is no moral difference per se between killing and letting die—is false. This is because a patient has the right to refuse treatment even when this is against his interest because the alternative would be forced treatment, but it is not true to say that a patient has the right to PAS even when it is against his interest. Also at issue is the Doctrine of Double Effect, according to which there is a moral distinction between an action that is intended to cause death and one that is merely foreseen to cause death. [End Page 224] In section I of this paper, I shall argue against DDE, which purports to disallow PAS but not refusal/withdrawal. I shall argue that since it is permissible for a physician to prescribe morphine to a patient suffering excruciating pain, it is also permissible for her to prescribe such a drug to a patient suffering pain, with the intention that he be killed and hence relieved of the suffering. The grounds on which I rely is the thesis that intention is irrelevant to permissibility, as proposed by Judith Thomson and T.M. Scanlon. In section II, I shall discuss David Velleman’s argument that termination of life is morally impermissible. I proceed to examine in section III the theoretical version of the Slippery Slope Argument. In section IV, I shall consider the practical version of the Slippery Slope Argument. In section V, I shall discuss other consequentialist objections to the legalisation of PAS. In the final section, I shall consider the view that even if PAS is morally permissible, it does not follow that it should be legalised. The argument I consider is the consequentialist one that legalising PAS may have a very different significance—when we consider the total consequences—than if there is only a single act of PAS, considered in isolation. While I agree that consequences are generally very important, I shall argue that we should approach the issue from a contractualist rather than a utilitarian perspective.3. (shrink)

Next SectionObjectives A statute enacted in 2005 modified the legislative framework of the rights of terminally ill persons in France. Ten years after the EURONIC study, which described the self-reported practices of neonatal caregivers towards ethical decision-making, a new study was conducted to assess the impact of the new law in neonatal intensive care units (NICU) and compare the results reported by EURONIC with current practices. Setting and design The study was carried out in the same two NICU as (...) in the EURONIC qualitative study. A third centre was added to increase the sample size. From February to October 2007, 19 physicians and 17 nurses participated in semistructured interviews very similar to those for EURONIC. Content analysis identified the recurring themes emerging from the interviews. Results Compared with the EURONIC results, the caregivers reported that they pay greater attention to the views of parents and provided respectful support to the neonates when life-sustaining treatment is withdrawn. Active termination of life has become exceptional. The possibility of withdrawal of treatment, the administration of sedatives to control pain even at the risk of hastening death, the emphasis on sparing parents the burden of decision, and the relative ignorance of the law were very similar to the EURONIC findings. Conclusion Both the medical and the legal regulation of practices has allowed more dialogue with the parents and more humane care for dying newborns. A new European study is necessary to investigate the possible changes in practices and attitudes also in other countries. (shrink)

In many countries, there are health care initiatives to make smokers give up smoking in the peri-operative setting. There is empirical evidence that this may improve some, but not all, operative outcomes. However, it may be feared that some support for such policies stems from ethically questionable opinions, such as paternalism or anti-smoker sentiments. This study aimed at investigating the support for a policy of smoking cessation prior to surgery among Swedish physicians and members of the general public, as (...) well as the reasons provided for this. A random sample of general practitioners and orthopaedic surgeons as well as members of the general public received a mail questionnaire. It contained a vignette case with a smoking 57-year old male farmer with hip osteoarthritis. The patient had been recommended hip replacement therapy, but told that in order to qualify for surgery he needed to give up smoking four weeks prior to and after surgery. The respondents were asked whether making such qualifying demands is acceptable, and asked to rate their agreement with pre-set arguments for and against this policy. Response rates were 58.2% among physicians and 53.8% among the general public. Of these, 83.9% and 86.6%, respectively, agreed that surgery should be made conditional upon smoking cessation. Reference to the peri-operative risks associated with smoking was the most common argument given. However, there was also strong support for the argument that such a policy is mandated in order to achieve long term health gains. There is strong support for a policy of smoking cessation prior to surgery in Sweden. This support is based on considerations of peri-operative risks as well as the general long term risks of smoking. This study indicates that paternalistic attitudes may inform some of the support for peri-operative smoking cessation policies and that at least some respondents seem to favour a “recommendation strategy” vis-à-vis smoking cessation prior to surgery rather than a “requirement strategy”. The normative reasons speak in favour of the “recommendation strategy”. (shrink)

Medical ethics changed dramatically in the past 30 years because physicians and humanists actively engaged each other in discussions that sometimes led to confrontation and controversy, but usually have improved the quality of medical decision-making. Before then medical ethics had been isolated for almost two centuries from the larger philosophical, social, and religious controversies of the time. There was, however, an earlier period where leaders in medicine and in the humanities worked closely together and both fields were richer for (...) it. This volume begins with the 18th century Scottish Enlightenment when professors of medicine such as John Gregory, Edward Percival, and the American, Benjamin Rush, were close friends of philosophers like David Hume, Adam Smith, and Thomas Reid. They continually exchanged views on matters of ethics with each other in print, at meetings of elite intellectual groups, and at the dinner table. Then something happened, physicians and humanists quit talking with each other. In searching for the causes of the collapse, this book identifies shifts in the social class of physicians, developments in medical science, and changes in the patterns of medical education. Only in the past three decades has the dialogue resumed as physicians turned to humanists for help just when humanists wanted their work to be relevant to real-life social problems. Again, the book asks why, finding answers in the shift from acute to chronic disease as the dominant pattern of illness, the social rights revolution of the 1960's, and the increasing dissonance between physician ethics and ethics outside medicine. The book tells the critical story of how the breakdown in communication between physicians and humanists occurred and how it was repaired when new developments in medicine together with a social revolution forced the leaders of these two fields to resume their dialogue. (shrink)

고통을 당하며 죽어가는 자를 고통에서 벗어나게 한다면, 그는 인간답게 죽을 수 있다. 하지만 고통 경감을 위해 생명을 중단한다면, 고통 경감도 의미를 잃어버릴 것이다. 고통 경감을 누릴 사람이 사라지기 때문이다. 또한 생명 중단을 수단으로 의도하여 고통 경감을 얻어낸다면, 이는 인간 존중에 어긋난다. 생명이 고통 경감을 위한 수단으로 사용되기 때문이다. 하지만 인간을 존중한다면, 인간 생명도 단지 수단으로 취급하면 안 된다. 의사조력자살을 정당화하려면, 이 난점을 해소해야 한다. 이 논문은 이를 위해 두 개의 논증을 제시한다. 평등논증은 평등 이념에 따라 의사조력사의 기회를 주는 것이 허용된다고 (...) 주장한다. 자연사하는 인간은 자신의 죽음에 대해 일정한 태도를 취할 수 있다. 반면 고통으로 인해 오직 죽음만을 바라는 절박한 인간은 그런 기회를 얻지 못한다. 그가 의사조력자살을 통해 그 기회를 얻을 수 있다면, 이는 허용될 것이다. 존엄논증은 의사조력자살을 허용하는 것이 금지하는 것보다 인간 존중에 대한 더 나은 해석이라고 주장한다. 의사조력자살을 허용하면 생명 중단과 고통 경감이 양립하며, 이에 반대하면 생명 유지와 고통 경감이 양립한다. 만약 전자가 후자보다 인간 존중에 대한 더 나은 해석임을 입증한다면, 의사조력 자살을 허용하는 것이 반대하는 것보다 인간 존중에 더 부합할 것이다. 따라서 평등논증과 존엄논증을 통해 의사조력자살에 대한 주요한 반론에 답변함으로써 의사조력자살 정당화 논증을 강화할 수 있다. (shrink)

The legal treatment of physician-assisted suicide is in flux. Reform has been impelled by several forces, including the recent success of novel constitutional arguments in the Ninth and Second Circuit Courts of Appeals. I will review and discuss Compassion in Dying v. State of Washington and Quill v. Vacco, addressing the constitutional arguments, and then briefly considering the attractions and difficulties of these new constitutional theories.Before 1990, state criminal laws dealing with assisted suicide had reached a remarkably stable consensus: suicide (...) was not illegal, but assisting suicide was a criminal action with no distinction typically made between physicians and others who assisted. The details of the relevant criminal law varied from state to state. Some states had criminal statutes specifically addressing assisted suicide, while others treated the practice under more general homicide statutes. But in no state was it clearly legal for a physician to prescribe a lethal medication at the request of a dying patient. While remarkable legal developments took place during the 1970s and 1980s regarding other aspects of the rights of dying patients, there was relative quiescence regarding the law of PAS. (shrink)

The job of being a sports team physician is difficult, regardless of the level, from high school to the National Football League. When a sports league receives the intensity of attention leveled at the NFL, though, a difficult occupation becomes even more challenging. Even for the NFL players themselves, players’ best interests regarding health issues are often unclear. Football players are, as a lot, highly competitive individuals. They want to win, and they want to help the team win. It's a (...) warrior culture, and respect is earned by playing hurt. Should the team physician respect a player's autonomy when this means allowing him to make choices that might lead to further personal harm, especially if the player's choices align with the preference of the coach and management? Or should the doctor set limits and balance the player's choices with a paternalistic set of constraints, perhaps in opposition to both the player's and the team's desires? Simplification of this web of conflicts of interest is the goal of the model proposed by Glenn Cohen, Holly Lynch, and Christopher Deubert. In my view, their proposal is very clever. As an idea, it meets the expectations its authors set, namely, to minimize the problem of conflict of interest in the delivery of health care services to NFL football players. The ethics of the proposal align well with certain moral goals, like treating the player's interests more fairly and treating the player's health as an end instead of as the means to an end. But will such a proposal ever make headway in the pressurized environment of the NFL? (shrink)

Even in the Netherlands, where the practice of physician-assisted death (PAD) has been legalized for over 20 years, there is no such thing as a ‘right to die’. Especially patients with extraordinary requests, such as a wish for PAD based on psychiatric suffering, advanced dementia, or (a limited number of) multiple geriatric syndromes, encounter barriers in access to PAD. In this paper, we discuss whether these barriers can be justified in the context of the Dutch situation where PAD is legally (...) permitted for those who suffer unbearably and hopelessly as a result of medical conditions. Furthermore, we explore whether there are options to address some of the barriers or their consequences, both within the Dutch legal framework or by adjusting the legal framework, and whether these options are feasible. We conclude that although there are insufficient arguments to overrule the doctor’s freedom of conscience in the Netherlands, there are ways to address some of the barriers, mainly by offering support to doctors that would be willing to support a request. Moreover, we believe it is morally required to reduce or mitigate where possible the negative consequences of the barriers for patients, such as the long waiting time for those who suffer from psychiatric disorders, because it is unlikely the adjustments suggested to the system will ensure reasonable access for these patient groups. (shrink)

Objectives— To explore British community pharmacists' views on PAS , including professional responsibility, personal beliefs, changes in law and ethical guidance.Design— Postal questionnaireSetting— Great BritainSubjects— A random sample of 320 registered full-time community pharmacistsResults— The survey yielded a response rate of 56%. The results showed that 70% of pharmacists agreed that it was a patient's right to choose to die, with 57% and 45% agreeing that it was the patient's right to involve his/her doctor in the process and to use (...) prescription medicines, respectively. Forty-nine per cent said that they would knowingly dispense a prescription for use in PAS were it to be legalised and 54% believed it correct to refuse to dispense such a prescription. Although 53% believed it to be their right to know when they were being involved in PAS, 28% did not. Most pharmacists said that they would wish to see the inclusion of a practice protocol for PAS in the code of ethics of the Royal Pharmaceutical Society of Great Britain in the event of a change in the law on PAS. In addition, 89% would wish to see PAS included in the Conscience Clause of the CE-RPSGB. Males were found to be significantly less likely to favour PAS than females , as were those declaring an ethnic/religious background of consideration when dealing with ethical issues in practice compared with their counterparts .Conclusion— Pharmacists view their professional responsibility in PAS to be more obligatory than a physician's, in having to provide the means for PAS. It is worrying that a proportion of the respondents prefer to remain in ignorance of the true purpose of a prescription for PAS; a finding at odds with current developments within the pharmaceutical profession. A practice protocol for PAS and an extension of the conscience clause should be considered in the event of PAS becoming legal. Such measures would allow the efficient provision of the pharmaceutical service whilst at the same respecting the personal beliefs of those who object to cooperating in the ending of a life. (shrink)

Doing Right: A Practical Guide to Ethics for Medical Trainees and Physicians is a concise and practical guide to ethical decision-making in medicine. The text is aimed at second- and third-year one-semester ethics courses offered in medical schools, health sciences departments, and nursing programs. By taking an applied approach rather than a theoretical approach, this text serves the needs of medical and nursing students, residents, and practicing physicians by sorting through questions of moral principles relevant to the diverse (...) and growing number of healthcare professionals. The many topics covered include truth telling, refusal of treatment, assisted suicide, managing error, and reproductive choice. (shrink)

Background Only a few studies have been conducted to assess physicians’ knowledge of legal standards. Nevertheless, prior research has demonstrated a dearth of medical law knowledge. Our study explored physicians’ awareness of legal provisions concerning informed consent and confidentiality, which are essential components of the physician-patient relationship of trust. -/- Methods A cross-sectional study assessed attending physicians’ legal knowledge of informed consent and confidentiality regulations. The study was conducted in nine hospitals in Dolj County, Romania. Physicians (...) were given a questionnaire with ten scenarios and instructed to select the response that best reflected their practice. We assessed the responses of physicians who claimed their practice to be entirely legal. Their legal knowledge was evaluated by comparing their answers to applicable laws. We also calculated a score for the physicians who admitted to committing a legal breach. -/- Results Of the 305 respondents, 275 declared they never committed any law violation. However, their median correct answer score was 5.35 ± 1.66 out of 10. The specialty was the strongest predictor of legal knowledge, with emergency physicians rating the lowest and non-surgical physicians scoring the highest. Physicians who worked in both private and public sectors were better knowledgeable about legal issues than those who worked exclusively in the public sector. Results indicate that physicians are aware of the patient’s right to informed consent but lack comprehensive understanding. While most physicians correctly answered simple questions, only a tiny minority identified the correct solution when confronted with ethical dilemmas. The physicians who acknowledged breaching the law, on the other hand, had a slightly higher knowledge score at 5.45 ± 2.18. -/- Conclusion Legal compliance remains relatively low due to insufficient legal awareness. Physicians display limited awareness of legal requirements governing patient autonomy, confidentiality, and access to health data. Law should be taught in all medical schools, including undergraduate programs, to increase physicians’ legal knowledge and compliance. (shrink)

Questions about the dignity of the human person give rise to many of the most central and hotly disputed topics in bioethics. In _A Defense of Dignity: Creating Life, Destroying Life, and Protecting the Rights of Conscience_, Christopher Kaczor investigates whether each human being has intrinsic dignity and whether the very concept of "dignity" has a useful place in contemporary ethical debates. Kaczor explores a broad range of issues addressed in contemporary bioethics, including whether there is a duty of (...) "procreative beneficence," the ethics of ectopic pregnancy, and the possibility of "rescuing" human embryos with human wombs or artificial wombs. _A Defense of Dignity_ also treats issues relevant to the end of life, including physician-assisted suicide, provision of food and water to patients in a persistent vegetative state, and how to proceed with organ donation following death. Finally, what are the duties and prerogatives of health care professionals who refuse in conscience to take part in activities that they regard as degrading to human dignity? Should they be forced to do what they consider to be violations of the patient's well being, or does patient autonomy always trump the conscience of a health care professional? Grounded in the Catholic intellectual and moral tradition, _A Defense of Dignity_ argues that all human beings from the beginning to the end of their lives should be treated with respect and considers how this belief should be applied in controversial cases. "_A Defense of Dignity_ provides a skillful, informed, and clear philosophical analysis, from a natural law perspective, of a range of controversial, and sometimes complex, bioethical questions concerning the beginning and end of life. Few authors approach bioethics from a natural law perspective, and few do it as well as Christopher Kaczor. The book should be of interest not only to natural law philosophers and their students, but also to anyone interested in bioethics." —_John Keown, Georgetown University__ "Moral questions at the beginning and ending of life and controversies over liberty of conscience are among the most vexing and important issues of our day. Christopher Kaczor brings his characteristic moral seriousness and philosophical good sense to his treatment of these issues, all of which implicate the key concept of human dignity. This eminently readable collection will provide an invaluable resource for educators and students alike." — Christopher Tollefsen, University of South Carolina_ “Indispensable. Kaczor untangles the various meanings of human dignity to undertake a reexamination of the most serious and difficult issues in medical ethics. The book combines clarity with philosophical precision, faithfulness to Catholic teaching with a thorough engagement with critics." —_J. Budziszewski, University of Texas at Austin_. (shrink)

In each US state that has legalized physician-assisted suicide, the law stipulates that it may be pursued only by terminally ill patients with a prognosis of six months or less to live. It appears that this requirement makes euthanasia laws more palatable for the general public. However, this restriction is not justified by the reasoning commonly used to support assisted suicide. The desire to alleviate suffering and uphold personal autonomy should require that assisted suicide be allowed for individuals who do (...) not have a six-month prognosis. The author concludes that a moral contradiction arises for individuals who support limited assisted suicide but oppose unrestricted suicide because acceptance of the former logically leads to acceptance of the latter. (shrink)

Over the past year the debate over physician-assisted death has been waged in several courts and legislatures, and before at least one electorate as well. Measure 16, the Oregon Death With Dignity initiative that would permit physician-assisted suicide in some circumstances, was approved by the electorate; but it remains on hold while a permanent injunction issued against it by a Federal judge is reviewed by the United States Court of Appeals. Another Federal court judge's decision that the Washington statute criminalizing (...) physician-assisted suicide was unconstitutional when applied to the case of a competent terminally ill patient in intractable pain, was reversed by a three judge panel of that same United States Court of Appeals. (shrink)

Three female physicians were interviewed as part of a comprehensive investigation into the narratives of female and male physicians and nurses, concerning their experience of being in ethically difficult care situations in the care of elderly people. The interviewees expressed great concern for the low status of care for elderly people, and the need to fight for the specialty and for the care and rights of their patients. All the interviewees’ narratives concerned problems relating to perspectives of (...) both action ethics and relational ethics. The main focus was on problems concerning the latter perspective, expressed as profound concern and respect for the individual patient. Secondary emphasis was placed on relationships with relatives and other professionals. The most common themes in an action ethics perspective were too little treatment and the lack of health services for older patients, together with overtreatment and death with dignity. These results were discussed in the light of Løgstrup’s ethics, which emphasize that human life means expressing oneself, in the expectation of being met by others. Both Ricoeur’s concept of an ethics of memory and Aristotle’s virtue ethics are presented in the discussion of too little and too much treatment. (shrink)

Since at least the advent of Jack Kevorkian’s “suicide machine” the major argument against adopting physician-assisted suicide laws has been that they will lead us down a slippery slope to state-sa...

In this paper, we analyze the legal situation regarding physician-assisted suicide in the world. Our hypothesis is that the prohibitive stance on physician-assisted suicide in most societies in the world today seems to be related to our moral attitudes toward suicide. This brings us to a discussion about life itself. We claim that the total lack of legal protection for physician-assisted suicide from international organizations and most countries in the world lies in a philosophical assumption that supports much of our (...) common beliefs about what life really is. This assumption states that life must be thought of as not belonging exclusively to the individual. We argue that this assumption is a misconception that can be heard in the debate on suicide. Consequently we endorse a different conception of life which tends to favor a pro-choice stance towards suicide and assisted death in general. This position takes the patient’s decision about when to die more seriously. We conclude that there is no reason why physician-assisted suicide does not deserve legal protection as an individual right to die under international law. (shrink)

Adequate response to physician-assisted suicide and euthanasia depends on fundamental philosophical and theological issues, including the character of an appropriate philosophically and theologically anchored anthropology, where the central element of traditional Christian anthropology is that humans are created to worship God. As I will argue, Christian morality and moral epistemology must be nested within and understood through this background Christian anthropology. As a result, I will argue that physician-assisted suicide and euthanasia can only be one-sidedly and inadequately appreciated through rational (...) appeal to central values, such as “human dignity” and “self-determination”, or through “sola scriptura” biblical interpretation, or individual judgments of conscience. Adequately addressing physician-assisted suicide and euthanasia will depend on a more fundamental spiritual-therapeutic approach. This cluster of moral, epistemological, anthropological, and bioethical claims will be explored by drawing on the texts of St. Basil the Great, St. Maximos the Confessor, and St. Isaac the Syrian. Their reflections on medicine, the human good, and its relationship to worship, spiritual therapy, and God will be used as a basis to indicate a broader philosophical perspective, which will be needed to avoid a one-sided, incomplete approach to the challenges of physician-assisted suicide and euthanasia. Medical morality, I argue, is best understood within categories that transcend the right, the good, the just, and the virtuous; namely, the holy. (shrink)

BackgroundIn the Netherlands, patients have the legal right to make a request for euthanasia to their physician. However, it is not clear what it means in a moral sense for a physician to receive a request for euthanasia. The aim of this study is to explore the moral values of physicians regarding requests for euthanasia. MethodsSemi-structured interviews were conducted with nine primary healthcare physicians involved in decision-making about euthanasia. The data were inductively analyzed which lead to the emergence (...) of themes, one of which was about values regarding end-of-life decisions.ResultsFour clusters of values related to euthanasia requests are described: values related to 1) the patient; 2) the family; 3) the physician; and 4) life and death. The data show that the participants value patient autonomy as a necessary but not sufficient condition for meeting a euthanasia request. A good relationship with the patient and the family are important. For the physician, the values physician autonomy, responsibility, understanding the patient and relief of suffering play a role. Life as an intrinsic good and a peaceful death are also important values.ConclusionThis study shows that next to patient autonomy and the relationship with the patient and the family, it is important for the participants to act in accordance with their professional values and to do justice to values related to life and death. The awareness of going against the intrinsic value of life is crucial, even if performing euthanasia may result in a feeling of relief or gratitude afterwards. (shrink)

Conscience can influence physicians’ interactions with patients in myriad ways and, by extension, can influence the interactions and internal dynamics of a health care team. The AMA’s opinion around physicians’ exercise of conscience appropriately balance the obligations physicians have to their patients and profession, and the rights of physicians as moral agents to exercise their conscience. While the opinion is an effective starting point, further guidance is necessary to clarify the process by which physicians (...) should identify, manage, and, if necessary, report their conscientious refusals to patients, supervisors, or colleagues. In addition to laying out a proposed process for identifying and managing issues of conscience, this article will use relevant and timely examples to help clarify how a physician could apply this process in an instance of conscientious refusal. (shrink)

BackgroundWhile healthcare professionals’ right to invoke the conscience clause has been recognised as a fundamental human right, it continues to provoke a heated debate in Polish society. Although public discourse is filled with ethical and legal considerations on the conscience clause, much less is known about the attitudes of healthcare professionals regarding that matter. The aim of this study was therefore to describe the attitudes of Polish physicians, nurses and pharmacists towards the ethical and legal aspects of the conscience (...) clause.MethodsWe analysed a group of three hundred healthcare professionals: physicians, nurses and pharmacists in Poznan, Poland, using a standard questionnaire comprising of 29 questions about various ethical and legal aspects of the conscience clause and participants’ personal experiences with the conscience clause. The study was conducted between January and March 2020.ResultsThis research shows that although most Polish healthcare workers support the right to invoke the conscience clause they differ significantly in their opinions on to whom and to what medical procedures the conscience clause should apply to. It also demonstrated that while the conscience clause is rarely invoked in Poland, most healthcare professionals declare that the current legal regulations in that sphere are unclear and inaccurate.ConclusionsWhile there is an urgent need to raise the awareness regarding the conscience clause among medical students and healthcare professionals and educate them about such issues, it is even more important to improve the legal system in regard to the CC so that it protects both HCPs’ right to the CC and safeguards patients’ rights to medical services. (shrink)

BackgroundBioethics and law distinguish between the practices of "physician-assisted death" and "allowing the patient to die."DiscussionAdvances in biotechnology have allowed medical devices to be used as destination therapy that are designed for the permanent support of cardiac function and/or respiration after irreversible loss of these spontaneous vital functions. For permanent support of cardiac function, single ventricle or biventricular mechanical assist devices and total artificial hearts are implanted in the body. Mechanical ventilators extrinsic to the body are used for permanent support (...) of respiration. Clinical studies have shown that destination therapy with ventricular assist devices improves patient survival compared to medical management, but at the cost of a substantial alteration in end-of-life trajectories. The moral and legal assessment of the appropriateness and permissibility of complying with a patient's request to electively discontinue destination therapy in a life-terminating act in non-futile situations has generated controversy. Some argue that complying with this request is ethically justified because patients have the right to request withdrawal of unwanted treatment and be allowed to die of preexisting disease. Other commentators reject the argument that acceding to an elective request for death by discontinuing destination therapy is 'allowing a patient to die' because of serious flaws in interpreting the intention, causation, and moral responsibility of the ensuing death.SummaryDestination therapy with cardiac and/or ventilatory medical devices replaces native physiological functions and successfully treats a preexisting disease. We posit that discontinuing cardiac and/or ventilatory support at the request of a patient or surrogate can be viewed as allowing the patient to die if--and only if--concurrent lethal pathophysiological conditions are present that are unrelated to those functions already supported by medical devices in destination therapy. In all other cases, compliance with a patient's request constitutes physician-assisted death because of the pathophysiology induced by the turning off of these medical devices, as well as the intention, causation, and moral responsibility of the ensuing death. The distinction between allowing the patient to die and physician-assisted death is pivotal to the moral and legal status of elective requests for death by discontinuing destination cardiac and/or ventilatory medical devices in patients who are not imminently dying. This distinction also represents essential information that must be disclosed to patients and surrogates in advance of consent to this type of therapy. (shrink)

Background There is little dispute that the ideal moral standard for surgical informed consent calls for surgeons to carry out a disclosure dialogue with patients before they sign the informed consent form. This narrative study is the first to link patient experiences regarding the disclosure dialogue with patient-surgeon trust, central to effective recuperation and higher adherence. Methods Informants were 12 Israelis, aged 29–81, who underwent life-saving surgeries. A snowball sampling was used to locate participants in their initial recovery process upon (...) discharge. Results Our empirical evidence indicates an infringement of patients’ right to receive an adequate disclosure dialogue that respects their autonomy. More than half of the participants signed the informed consent form with no disclosure dialogue, and thus felt anxious, deceived and lost their trust in surgeons. Surgeons nullified the meaning of informed consent rather than promoted participants’ moral agency and dignity. Discussion Similarity among jarring experiences of participants led us to contend that the conduct of nullifying surgical informed consent does not stem solely from constraints of time and resources, but may reflect an underlying paradox preserving this conduct and leading to objectification of patients and persisting in paternalism. We propose a multi-phase data-driven model for informed consent that attends to patients needs and facilitates patient trust in surgeons. Conclusions Patient experiences attest to the infringement of a patient’s right to respect for autonomy. In order to meet the prima facie right of respect for autonomy, moral agency and dignity, physicians ought to respect patient’s needs. It is now time to renew efforts to avoid negligent disclosure and implement a patient-centered model of informed consent. (shrink)

In today’s globalized world, nations cannot be totally isolated from or indifferent to their neighbors, especially in regards to medicine and health. While globalization has brought prosperity to millions, disparities among nations and nationals are growing raising once again the question of justice. Similarly, while medicine has developed dramatically over the past few decades, health disparities at the global level are staggering. Seemingly, what our humanity could achieve in matters of scientific development is not justly distributed to benefit everyone. In (...) this paper, it will be argued that a global theoretical agreement on principles of justice may prove unattainable; however, a grass-roots change is warranted to change the current situation. The UNESCO Declaration on Bioethics and Human Rights will be considered as a starting point to achieve this change through extracting the main values embedded in its principles. These values, namely, respecting human dignity and tending to human vulnerability with a hospitable attitude, should then be revived in medical practice. Medical education will be one possible venue to achieve that, especially through role models. Future physicians will then become the fervent advocates for a global and just distribution of health care. (shrink)

In this paper it is argued that physicians’ restrictive attitudes in offering abortions during 1946–1965 in Sweden were due to their private values. The values, however, were rarely presented openly. Instead physicians’ values influenced their assessment of the facts presented—that is, the women's’ trustworthiness. In this manner the physicians were able to conceal their private values and impede the women from getting what they wanted and needed. The practice was concealed from both patients and physicians and (...) never publicly discussed. It is also argued that a similar tacit practice could currently be applied by palliative care physicians. Such practice might allow palliative care physicians to be restrictive when offering sedation therapy without appearing paternalistic or declaring conscientious objections. However, the practice runs counter to patients’ right to participate in making decisions. The women seeking abortion began to oppose the situation and eventually a new abortion law was introduced 1975. Patients at the end of life will never be able to protest against palliative care physicians’ restrictive attitudes. This is a vulnerable and weak group, unable to lodge complaints after the treatment. In order to respect patients’ autonomy, even suffering patients at the end of their lives, it is suggested that physicians should openly declare their values when it comes to providing treatments that might shorten life. Such transparency might facilitate more genuine shared decision-making and accordingly less suboptimal end-of-life care. (shrink)

Volume 20, Issue 9, September 2020, Page 26-28.