Armstrong describes the rise of a new mode of medical practice that he calls in the following terms: Surveillance medicine gives rise to a novel and underexplored aspect of the long-standing tension between the different goals of clinical medicine and public health.
There has been a modern epidemic of heart attacks in the western world, and this paper is concerned with this ânewâ medical condition and how it arose. Two competing theories are commonly proposed, relating either to conventional accounts of medical science, or to social construction. Whilst recognising that aspects of both theories have some validity, it is claimed that neither is wholly adequate. This issue has particular relevance for heart attacks and is explored in some detail, but it also points (...) to some more general conclusions. First that medical knowledge cannot be separated into âscientificâ and âsocialâ compartments but is united by its human aspect; and second that although medical knowledge has a special dimension, when understood in this way, it may also resonate with a more general re-examination of the relationship between scientific and human knowledge. (shrink)
During the past thirty years a high proportion of all long stay hospital beds have been closed. The responsibility for those who would have occupied those beds previously has to a large extent been transferred from health to social services departments, or to family, voluntary and private care. The overall effect has been to prioritize acute medical care, and to expose the public provision and funding of long term residential care, whether medical or social, to the direct determination of political (...) and economic forces. These policy changes have been introduced under the banner of community care, but are dependent on complex concepts which are morally contentious and often obscure. The purpose of this paper is to analyse these processes as a prerequisite to devising better policies in future. (shrink)
Section 47 of the National Assistance Act is controversial in that it makes provision for the compulsory removal and care of mentally competent adults in certain limited circumstances. A case is described in which it is argued that compulsory management could be justified. This is because the diversity and potentially conflicting nature of the relevant considerations involved in this and a restricted range of other cases, defies their being captured in any wholly rational moral scheme. It follows that if the (...) law is to be both sensitive and just it cannot always provide definitive guidance as to how the community doctor, as the designated decision-maker, should act. The acceptance of his or her judgement is therefore necessary and depends for its proper working on trust, which can only be gained through compassion and respect for the patients concerned. (shrink)
Following the first enactment of living will legislation in California in 1976 the majority of the states of the USA have now passed similar laws. However, flaws have been identified in the way they work in practice and many states are considering reviewing their legislation. In Britain there is no legislation but the subject is currently commanding considerable interest. This paper assesses the future prospects for living wills in both the USA and Britain, analysing the different options available and comparing (...) the two countries. If patients who become permanently incompetent are to have their previous autonomous decision-making respected, there is general agreement that advance directives for health care must be introduced. The difficulty is in deciding how to implement them, and especially whether this should be by statutory or non-statutory means, the traditions in the two countries being very different in this respect. It is concluded that whichever route is taken, promoting respect for patient autonomy is as much a matter for education and persuasion of doctors as of the adoption of particular instruments. Doctors should therefore be trained in what constitutes good medical practice in this area and, to ensure that it can be carried out properly, the general level of medical facilities for these patients must also be protected and promoted. (shrink)
A postgraduate Diploma in Medical Ethics and Law was started in October 1984 by the Centre of Medical Law and Ethics at King's College. It is a part-time one year course designed so as to enable students to continue with full-time employment if they wish. It is multidiscipinary and is open to all who have a first degree in a relevant discipline, for example law, philosophy, theology, medicine and nursing studies. It is unique in combining medical law and medical ethics (...) and has attracted students of high calibre from a variety of backgrounds during its first three years. Building on the experience of the diploma the course is being upgraded to an MA in 1987-88. It will be available either full-time for one year or part-time for two years. (shrink)
The failure of Western medicine to deal with many of the problems it is currently facing has led to an awareness of the need for a fundamental reappraisal. The way in which medical concepts derived from the nineteenth century have brought technical medical advances in this century and the alliances that medicine has made with statistics and more recently the social sciences, have prevented a questioning of medicine's underlying assumptions. Thus, despite a number of critical initiatives from both within and (...) outside medicine, there has been no coherent development to seriously confront the question 'what is medicine?'. It is suggested that the basis for such a development depends on the return to a philosophical questioning of our conceptual understanding of disease, a subject which has largely been ignored during the past hundred years. (shrink)