Among the important functions of the healthcare provider in providing quality care is the monitoring of the social environment of the patient. Although it is increasingly recognized that caring activity must include the whole patient and not merely the technical and pharmacological aspects of the patient's needs, the impact of the social environment upon the total health state has not been explored and debated to the extent that It might be.

In celebration of the fortieth anniversary of the publication of Beauchamp and Childress’s Principles of Biomedical Ethics, a review is undertaken to compare the lists of principles in various bioethical theories to determine the extent to which the various lists can be reconciled. Included are the single principle theories of utilitarianism, libertarianism, Hippocratism, and the theories of Pellegrino, Engelhardt, The Belmont Report, Beauchamp and Childress, Ross, Veatch, and Gert. We find theories all offering lists of principles numbering from one (...) to ten. Many of the differences can be reconciled, but some critical differences remain. (shrink)

When a new, brain-based definition of death was proposed fifty years ago, no one realized that the issue would remain unresolved for so long. Recently, six new controversies have added to the debate: whether there is a right to refuse apnea testing, which set of criteria should be chosen to measure the death of the brain, how the problem of erroneous testing should be handled, whether any of the current criteria sets accurately measures the death of the brain, whether standard (...) criteria include measurements of all brain functions, and how minorities who reject whole-brain-based definitions should be accommodated. These controversies leave little hope of consensus on how to define death for social and public policy purposes. Rather, there is persistent disagreement among proponents of three major groups of definitions of death: whole-brain, cardiocirculatory or somatic, and higher-brain. Given the persistence and reasonableness of each of these groups of definitions, public policy should permit individuals and their valid surrogates to choose among them. (shrink)

We are living in an unprecedented era of biomedical revolution. Medicine is remaking humans, and controversy surrounds such topics as abortion, artificial organs, brain circuitry, eugenics, euthanasia, and gene therapy. At the same time, medical advances are posing complex ethical problems for both patients and professionals. The most comprehensive and up-to-date collection of its kind, Case Studies in Biomedical Ethics: Decision-Making, Principles, and Cases explores fundamental ethical questions arising from real situations faced by health professionals, patients, and others. Featuring a (...) wide range of more than 100 case studies drawn from current events, court cases, and physicians' experiences, the book is divided into three parts. Part I presents a basic framework for ethical decision-making in healthcare, covering such issues as separating evaluative questions from questions of fact; distinguishing between ethical and nonethical evaluations; and identifying the source of ethical judgments. Expanding upon this framework, Part II explains the ethical principles: beneficence and nonmaleficence, justice, respect for autonomy, veracity, fidelity, and avoidance of killing. Parts I and II provide students with the background to analyze the ethical dilemmas presented in Part III, which features cases on a broad spectrum of issues including abortion, genetics, mental health, confidentiality, health insurance, experimentation on humans, the right to refuse treatment, and death and dying. Each case is accompanied by the authors' commentary, which guides students in considering the issues. Ideal for undergraduate and graduate courses in biomedical ethics, bioethics, and medical ethics, Case Studies in Biomedical Ethics incorporates opening text boxes in each chapter that cross-reference relevant cases in other chapters. It also includes an appendix of important ethical codes and a glossary of key terms. (shrink)

Assesses the ethical problems that doctors face every day and advocates a more universal code of medical ethics, one that draws on the traditions of religion and philosophy.

When The Ad Hoc Committee of Harvard Medical School to Examine the Definition of Brain Death began meeting in 1967, I was a graduate student, with committee member Ralph Potter and committee chair Henry Beecher as my mentors. The question of when to stop life support on a severely compromised patient was not clearly differentiated from the question of when someone was dead. A serious clinical problem arose when physicians realized that a patient's condition was hopeless but life support perpetuated (...) body function. Thus, the committee stated that its first purpose was to deal with the burdens on patients and families as well as on hospitals and on patients needing hospital beds occupied by comatose patients. They intuited the strategy of “defining” these patients as dead, thus legitimating treatment stoppage. They noted that this would also serve a second purpose. Although the dead donor rule had not yet been clearly articulated, they claimed that defining patients as dead would also address controversy over obtaining organs for transplant.My mentors’ discussions related to my interest in the intersection between questions primarily of medical fact (When has a human brain irreversibly ceased functioning?) and nonmedical questions of social policy (Should we treat individuals with dead brains and beating hearts as dead humans?). It quickly became clear that most committee members did not appreciate the interplay of these questions. (shrink)

The dead donor rule (DDR) governs procuring life-prolonging organs. They should be taken only from deceased donors. Miller and Truog have proposed abandoning the rule when patients have decided to forgo life-sustaining treatment and have consented to procurement. Organs could then be procured from living patients, thus killing them by organ procurement. This proposal warrants careful examination. They convincingly argue that current brain or circulatory death pronouncement misidentifies the biologically dead. After arguing convincingly that physicians already cause death by withdrawing (...) treatment, they claim no bright-line differences preclude organ removal from the living. The argument fails for those who accept the double effect doctrine or other grounds for distinguishing forgoing life support from active, intentional killing. If the goal is determining irreversible loss of somatic function, they correctly label current death pronouncement a “legal fiction.” Recognizing a second, public policy meaning of the term death provides grounds for maintaining the DDR without jeopardizing procurement. (shrink)

‘Apologetics’ is hardly a word to be used without apology in the present dispensation. And to speak of anything like a neglected avenue or opportunity in religious apologetics might almost seem as if one were speaking of an opportunity in just such an enterprise as no self-respecting philosopher would nowadays wish even to be associated with. For all of their avoidance of the term, however, the thing designated by the term is something with which not a few philosophers of recent (...) years have been not above dabbling in, albeit usually under other names and other labels. After all, religious language has now come to be recognized as not just a legitimate, but even a fashionable object of philosophic attention. And a concern with religious language has often brought with it a concern with religious attitudes, religious behaviour, religious argumentation — yes, even to the point of occasionally becoming a concern with the very religious realities themselves that religious language, religious attitudes, religious behaviour, and religious argument are presumably all about. True, religious realities in this sense are to today's garden of philosophy pretty much what the tree of knowledge once was to the garden of Eden. In fact, one even suspects that there could be a serpent about somewhere, for cases have been reported of an occasional philosopher Adam or philosopher Eve having yielded to temptation: a consideration of God-talk has been known to lead to cautious admissions that such talk might be cognitively meaningful; a consideration of God-experiences to the admission that such experiences under certain circumstances could be veridical; or, even more rarely, a consideration of proofs for God's existence to the gingerly admission that at least some of these proofs might just possibly be valid. Needless to say, though, such a yielding to temptation on the part of some few contemporary philosophers, while it may not have led to any manifest sewing together of fig-leaves, has certainly brought with it the danger, if not always the reality, of a supercilious expulsion from the glorious Eden of contemporary professional philosophy. (shrink)

No one really believes that literally all functions of the entire brain must be lost for an individual to be dead. A better definition of death involves a higher brain orientation.

Twelve contributors discuss critical issues affecting medical ethics. Topics include: the normative principles of medical ethics, concepts of health and disease, the physician-patient relationship, human experimentation, informed consent, genetics, ethical issues in organ transplantation, and moral.

This anthology of major classical and contemporary views on key ethical aspects of death and dying is the only philosophically sophisticated, interdisciplinary, and up-to-date introduction to the subject available. Pairs pro and con arguments to give a balanced perspective. Covers a range of topics that reflect the latest developments at the frontier of the field. Provides clearly and carefully written section introductions that define the issues to be discussed. Introduces each selection with a brief editorial essay. Features up-to-date and solid (...) analyses of all issues. Offers an excellent introduction to ethical theory. (shrink)

This book is a consideration of the differences between Aristotelian and symbolic logic (and the metaphysical assumptions they come packaged with) and the consequences these have for how we view the world. What Veatch propose is to try to exhibit with respect to several of the key logical tools and devices – propositions, inductive and deductive arguments, scientific and historical explanations, definitions, etc. – how these several instruments are differently conceived, both as to their natures and their functions, in (...) each of these respective logics. (shrink)

The Foundations of Justice: Why the Retarded and the Rest of Us Have Claims to Equality. By Robert M. Veatch.

Many pharmaceuticals are available to patients only with a physician’s prescription. Although it is often not recognized as such, this is a classic example of paternalism in public policy. Pharmaceuticals are often perceived as carrying dangerous side effects. Access is restricted to protect patients from their own bad decisions. This chapter explores the moral justification for such paternalism and finds it wanting. It raises the question of whether there is adequate justification for this restriction. Consistency requires that pharmaceuticals posing dangers (...) primarily to the individual be available to competent consumers and that even moderate risks to third parties be tolerated. The chapter begins by arguing that all drug usage involves evaluative judgments about the relative benefits and harms of the agents and that physicians must make value judgments in deciding whether to prescribe. (shrink)

“Big ticket” items in medicine pose a moral puzzle. We can call it the “Coby Howard puzzle,” after the boy whose need for an expensive bone marrow transplant forced Oregonians to reassess their policy of prohibiting this and other expensive “big ticket” procedures in favor of more low-tech, apparently cost-efficient interventions. The Oregon rationing debate was stimulated by the concern that expenditures on “big ticket” medical treatments for life-threatening disease were coming at the expense of low-tech, preventive “basic” care like (...) immunizations, wellbaby clinics, and prenatal care.Another recent example was the public controversy over expenditures of over $1,800 per day on a project to try to separate Siamese twins conjoined at the heart. The physicians, prior to the procedure, claimed there was a one percent chance of success. It was reported that 50,000 children in Philadelphia could be immunized at the cost of that innovative therapy. Cost-benefit analysis suggests that much greater good would be done in the long run if we ignored the expensive, long-shot, high-risk projects and focused on basic medical needs. (shrink)

A “white coat” ceremony functions as a rite of passage for students entering medical school. This comment provides a second option in response to the earlier, more enthusiastic, discussion of the ceremony by Raanan Gillon. While these ceremonies may serve important sociological functions, they raise three serious problems: whether the professional oath or “affirmation of professional commitment” taken in this setting has any legitimacy, how a sponsor of such a ceremony would know which oath or affirmation to administer, and what (...) the moral implications of this “bonding process” are. I argue that the initiation oath is morally meanignless if students are not aware of its content in advance, that different students ought to commit to different oaths, and that bonding of students to the medical profession necessarily separates them from identification with lay people who will be their patients. (shrink)

When I arrived at Harvard as an incoming graduate student in the fall of 1964, I soon received a telephone call from a gentleman who introduced himself as Henry Beecher. I was in the process of shifting my graduate studies from research neuropharmacology to the study of ethics. Robert Featherstone, the head of the Department of Pharmacology at the University of California Medical Center, San Francisco, where I had been studying, was a specialist in anesthesiology and knew Henry Beecher, who (...) was also working in anesthesiology, well. He had contacted Beecher, alerting him to the fact that a new graduate student was arriving and that it appeared that the two of us had much in common. The phone call from Beecher... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:IntroductionRobert M. Veatch (bio)The Kennedy Institute of Ethics regularly sponsors intensive bioethics courses for physicians, nurses, and other health care professionals. While the basic course, held in June of each year, provides a general introduction to bioethics, advanced courses, which are often held in March, focus on more specific topics such as death and dying, justice and the allocation of resources, or theories and methods in bioethics. This (...) year the advanced course addressed one of the most sensitive and complex bioethical issues of our day: managed care. This issue of the Kennedy Institute of Ethics Journal includes revised versions of many of the papers from that meeting.As defined by one of the papers in this issue, managed care involves a system of health care delivery that manages resources, quality, and access associated with the delivery of health care. The key element of managed care is that, for the first time, managers—often from outside the health care professions—are intentionally controlling resources, and therefore controlling health care professional decisions that use those resources. The objective is not merely to eliminate utterly useless interventions—no one could plausibly object to that. Rather the target is also the elimination of inefficient and wasteful resource consumption. Increasingly, we recognize that many diagnostic tests and treatments offer, at best, a very marginal chance of doing the patient good. Some of these come at considerable cost. From the point of view of the rational organization of resources, no rational person would insist on receiving every last procedure that offers only a tiny chance to do a small amount of good at great cost. Managed care is designed to bring to consciousness and rationalize the decisions about which of these marginal, expensive benefits are worth pursuing.The problem is that any effort to eliminate any of the these expensive marginal services flies directly in the face of the Hippocratic ethic. Physicians and other clinicians traditionally are trained to believe that it is their moral duty to do what is best for the patient. Only now are we realizing that, taken literally, no rational person would want literally the best possible care, assuming that such care would include thousands of long-shot, expensive efforts to get the most modest of benefits at great cost. In a world of finite resources, rational people would certainly want very good medical care; they would want reasonable care. But they would also want some criteria of efficiency and fairness applied. The Hippocratic tradition has never addressed the problem of the difference between the best care and care that is of very high quality, but is chosen with an awareness that the best in medicine will necessarily come at the price of potentially serious [End Page vii] deprivation in other spheres of life. The ethics of managed care is fundamentally an exploration of how health care professionals can reconcile their traditional, if short-sighted and naive, commitment to doing what is best for their patients with increasing realism about the absurdity of pursuing every last possible increment of benefit.To the clinical health care professional, the issue raised most poignantly by managed care is whether the various health professions can still be practiced with integrity in a setting in which outsiders are charged with the rationalization and systematization of limits placed on excessive use of marginally beneficial resources. Edmund D. Pellegrino, a clinician and former Director of the Kennedy Institute, sets the tone for the course and for this issue of the Journal by making an appeal for the retention of the highest ethical standards of integrity for clinicians practicing in a managed care setting. He is unwilling to let standards be lowered in the process of systematizing the rational use of health care resources. The remaining papers in this issue respond to those pressures to change the nature of the clinical lay-professional relationship. Some of these presentations originated as panels designed to bring out varying points of view. The published form of the presentations, like the original oral remarks, are of different lengths. All have been edited by the presenters, some taking on the form of more finished papers, others still reflecting the less formal conversation of... (shrink)