Physician-Assisted Suicide in the United States: Confronting Legal and Medical Reasoning – Part Two

In the United States, judicialrulings that unrealistically addressed the complexityof cases and demonstrated limited understanding ofprinciples, helped to create a legal quagmire whichlegislatures had to confront. Moreover, thelegislative response was often slow and inadequate interms of both the scope and clarity of the laws. However, since the 1970s, progress has been made onmany fronts, particularly in regard to advancedirectives dealing with end-of-life decisions. Thedebate over physician-assisted suicide has spawned arepetition of moral and legal arguments. Thoseagainst legalization have failed to make a realisticappraisal of the dilemmas facing patients and theirfamilies in an age of technological medicine deliveredin the context of the marketplace. The underlyingproblem is a system in dire need of reform that willno longer treat health care as a commodity of themarketplace and provide universal health care. Terminal care as an integral part of health care willsubstantially benefit from such reforms because amajor obstacle to comprehensive palliative care is thecondition of the present system.     

癌症姑息治疗的临床意义和社会伦理思考

姑息医学作为医学学科之一,内容包括癌痛控制,处理缓解其他症状。癌症姑息治疗缓解了紧张的医患关系,有效的防止有限医疗资源的浪费及分配不公,同时姑息治疗给人们留下诸多社会伦理思考,如告知、癌痛控制等问题。如何将姑息治疗扩展到其他非恶性疾病面临着巨大挑战。     

鼻咽癌的姑息治疗

鼻咽癌诊断的复杂性及诊断水平的限制,很多的患者确诊时已是中晚期。姑息治疗作为一种新的医疗模式,能减轻鼻咽癌患者的痛苦,提高生存质量。姑息治疗的发展将提高癌症治疗效果,为患者带来希望。     

从哲学眼界论医学、健康安全与卫生经济

从哲学眼界看,医学与健康都是多元的概念,是许多相互交叉、渗透、影响、制约的因素互相作用的结果。医学、健康保健应适应经济水平,即我们应向患者及社会提供一个安全的、科学的、用的起的、可持续的医疗与健康保健服务。较多贪婪的、不安全的医学时代,最好的计划是不断进行几元钱的预防医学投入和适当的姑息医学。     

姑息治疗及其在肿瘤学中的地位

本文对姑息治疗的历史及概念作了详细的介绍,解释了其不同阶段的内涵,作为医学学科之一,姑息治疗的内容主要包括了疾病伴随或治疗所致症状的诊断评估、预防和治疗,心理和非癌性躯体疾病的预防和治疗,姑息治疗的科研、教学和教育以及终末期病人的治疗和护理等,特别纠正了对“安乐死”的看法。在肿瘤学中,经过40多年,它已从治疗中的辅助角色迅速成为肿瘤综合治疗中的主角,且贯穿于始终。它倡导多学科协作,与抗癌治疗完整结合,对无法治愈的晚期癌症患者以缓解症状、改善生活质量为主要目标,在全球范围内,很大一部分晚期肿瘤病人已从姑息治疗中明显获益。它的有力实施,也是我们创建和谐社会的重要反映。     

台湾地区姑息医学制度的建立及法律实践

姑息治疗在提高晚期癌症患者生活质量、实施临终关怀、给予病人及其家属全面周到的照顾诸方面起着重要作用。在台湾,已为姑息治疗立法并实施了10年,积累了丰富的经验。这项法律本身及其细则、附件等配套文件使姑息治疗更加规范可行。研究规范的姑息治疗及台湾的相关法律可以帮助我们更好的理解姑息治疗的理念,帮助发展大陆同道构建有效实用的...     

Practical Matters and Ultimate Concerns, “Doing,” and “Being”: A Diary Study of the Chaplain's Role in the Care of the Seriously Ill in an Urban Acute Care Hospital

Systematic observational studies of the chaplain's role and function in the secular health‐care setting are few. With an episode‐based diary recorded on handheld digital tablets, palliative care chaplains at a large urban hospital with a diverse patient population recorded details of patient visits in near‐real time. Cluster analysis revealed groups of activities we called "doing" and "being," and conversation topics of "practical matters" and "ultimate concerns”; chaplains were most satisfied with visits that involved all of these. Chaplains offer patients and families a space to express significant concerns; however, visits with spiritual or religious activities or topics were relatively rare. Broad quality of life concerns are central to the evolving professional role of chaplains in the secular setting of the modern hospital.     

晚期癌症患者治疗决策的思考

现代医疗尚无法治愈所有晚期癌症。现实与期望之间的较大差距,挑战晚期癌症治疗的临床决策。WHO强调为防止资源滥用,应确保抗癌治疗只用于可获益阶段。对于晚期癌症患者的治疗决策,除遵循规矩原则和循证医学证据原则外,还应该遵循尊重患者意愿、社会公平的美德原则。大多数癌症患者需要接受姑息治疗。姑息治疗为患者及家属提供既简便又经济的医疗服务。     

宁养医学课程与医学生人文关怀

介绍宁养医学的定义,在医学生中开设宁养医学课程的做法、体会和存在问题.在此基础上,提出了宁养医学课程有助于在医学生中普及照顾不可治愈病人的原则和知识,培养人文关怀的理念,因此建议将其列为必修课.     

现代姑息医学内涵在实践中的演化

积极开展姑息医学服务已成肿瘤临床工作者的共同实践,并使其在实践中得到发展。姑息医学在肿瘤整体治疗中的作用和地位已逐渐受到同行的认同,提高了肿瘤工作者对姑息医学实践的参与热情,使业内有识之士从全新的角度对姑息医学的内涵进行审视。本文拟结合姑息医学的发展历程及不同分期肿瘤患者姑息治疗的内容介绍现代姑息医学内涵的演化过程。     

肿瘤姑息治疗的全程介入

恶性肿瘤严重威胁人类健康,肿瘤本身以及针对肿瘤的治疗不仅会对患者的生理和心理产生重要影响,同时也会对照顾患者的家人产生各种心理影响。现有医疗条件下短时间内难以提高治愈率,就应更加注重将姑息治疗贯穿于肿瘤治疗的始终,不仅要及早介入,甚至延伸至居丧期。在肿瘤治疗过程中不断对肿瘤患者进行评估和适时调整姑息治疗策略,可有效地提高患者生活质量同时降低医疗成本,最终患者能够在不同阶段和各种治疗手段中获得最大受益。     

姑息医学在大肠癌治疗中的地位和应用策略

大肠癌的治疗应采用一种无缝的连接方式将姑息治疗与抗肿瘤治疗整合在一起。姑息医学的采用应贯穿肿瘤治疗的始终,以期更好地提高生命质量,尊重生命价值,体现医学本质和人文关怀。     

The difficulties assessing spiritual distress in palliative care patients: a qualitative study

This paper reports on a focus group study aimed at exploring the difficulties that palliative care healthcare professionals encounter while assessing the spiritual distress of their patients. Three focus groups were conducted in a hospice (n = 15). Participants were all healthcare professionals working in the hospice in-patient unit. Interviews were taped and later transcribed. The data was analysed through content analysis. Emergent themes included: lack of vocabulary around spiritual issues, personal issues surrounding death and dying, training issues, fear of being unable to resolve spiritual problems, time constraints and difficulty separating spiritual and religious needs. Participants provided a number of recommendations for improving care. This pilot study has generated useful data in relation to how spiritual care of patients might be improved. Despite the abundance of academic publications and policies on spirituality, this area is not integrated well into palliative care.     

Body language and metaphors revealed through applications of Movement Psychotherapy in a hospice: A clinical case of refractory pruritis

Movement psychotherapy (MP), and dance/movement therapy (DMT), are body-orientated psychotherapy approaches that use movement for the integration of emotional, cognitive, physical, social and spiritual aspects of self (European Association Dance Movement Therapy, 2010). It is distinctively a combination of moving and sensing the body with verbal self-reflection (Bloom, 2006). Several papers have presented DMT as a treatment in general medical care and cancer care, but there is still a paucity of evidence-based studies. The authors describe a clinical case illustrative of many of the situations in which facing death was particularly tormenting. The emotional pressure can produce a barrier of communication with the risk of rupturing the therapeutic relationship. The movement therapist’s function is to clarify the elements of body language and this has important implications for clinical practice because the end-of-life decisions are difficult, like palliative sedation therapy (PST). Even if procedural guidelines for PST help physicians and care teams through the decision-making process and make them more comfortable when responding to physical suffering, physicians more frequently report an emotional pressure when their patients experience psychological symptoms, with the risk that PST could become a potential “counterphobic defence to treat”.     

Examining the Ethics of Clinical Use of Unproven Interventions Outside of Clinical Trials During the Ebola Epidemic

The recent Ebola outbreak in West Africa began in the spring of 2014 and has since caused the deaths of over 6,000 people. Since there are no approved treatments or prevention modalities specifically targeted at Ebola Virus Disease (EVD), debate has focused on whether unproven interventions should be offered to Ebola patients outside of clinical trials. Those engaged in the debate have responded rapidly to a complex and evolving crisis, however, and this debate has not provided much opportunity for in-depth analysis. Additionally, the existing literature on access to unproven therapies has focused on contexts like HIV/AIDS and oncology, which are very different than the Ebola epidemic. In this paper, we examine the ethical issues surrounding access to unproven therapies in the context of the recent Ebola outbreak to yield new insights about this controversial and unsettled issue. We argue first that, in this context, the interests of patients in obtaining access to unproven therapies are not fully aligned with the interests of their providers and drug developers. Second, we focus on the resource constraints facing providers, funders, and patients and conclude that they often counsel against the use of unproven interventions against EVD.     

A quality assurance programme for psychotherapy — The finnish experience

In many respects the status of psychotherapy in public health-care systems is similar to that of alternative medicine. The roots of training are outside universities. Legitimation and public funding have been non-existent or insufficient as compared with other fields of health care. Also a great deal of mysticism is attached to both. It is therefore relevant to study the role of psychotherapy from the frame of reference given by research into alternative health care.

Formal health care is characterised by (1) legalised status, (2) access to public funding and (3) integration in the formal medical curriculum. On the other hand there are several treatment philosophies which remain as outsiders from the point of view of formal health care. Informal health care approaches are characterised by (1) lack of legalised status, (2) no access to public funding and (3) no integration in the medical curriculum. Alternative medicine is a term usually attached to forms of informal health care like acupuncture, Spa-culture etc.

Psychotherapy in the public health sector lies somewhere between formal and informal health care. While it has no legalised status, anyone may call himself ‘psychotherapist’. Its definition remains obscure and its public accountability poor.

In this paper I have tried to show how one country — Finland — has tried to grapple with this problem as it attempted to set up psychotherapy services whose quality could be properly monitored — ‘Quality Assurance’ — allowing for public accountability. Now that psychotherapy is well established as a valuable treatment in the field of mental health it is possible to consider future expansion as a cost-effective way to improve the general mental health of the country.     

Patient-provider care goal concordance: implications for palliative care decisions

Objective: Goal-concordant care is an important feature of high quality medical treatment. Patients’ care goals may focus on curative and/or palliative outcomes. Patients rarely communicate their care goals, and providers’ predictions of patient goals are often inaccurate, corresponding most closely to their own treatment goals. This projection of own goals onto patients introduces the potential for bias, leading to goal-discordant care.

Design and Main Outcomes: We examined goal discordance using data from a U.S. sample of healthcare providers (N?=?492) recruited online in 2017 using GfK Knowledge Panel. Providers reported their perceptions of their patients’ care goals (curative relative to palliative), their own care goals if they were to become ill, and their willingness to deliver palliative care.

Results: For 28% of providers, their own care goals differed from their patients’. Providers were more likely to prioritise palliative care (relative to curative) in their own goals than in their predictions about patients’ goals. Providers were more willing to deliver palliative care when their own goals prioritised more palliative relative to curative care, but their perceptions of patient goals were unassociated with willingness to provide it.

Conclusions: Efforts to improve goal communication and reduce projection biases among providers may facilitate goal-concordant care.     

The case of Peter: reflections on applied ethics in a neonatal intensive care unit

The case of Peter is reflected upon in order to highlight some of the moral theorising that could be brought to bear in the process of providing palliative care for sick neonates. The situation will be discussed using the theoretical lenses of deontological and virtue ethics. Nursing practice is considered as engaged moral reasoning where the nurse brings his/her beliefs, knowledge and experience into the situation and engages in reflexivity to provide appropriate ongoing patient care. The care should be provided in culturally sensitive manner and tailored to the needs of the newborn and their family. Nurses should initiate early consultations with colleagues, medical staff and families to address concerns about patient well-being in order to enhance the well-being of patients and families and to improve the work environment making it more conducive to care.     

On counterpossibles

The traditional Lewis–Stalnaker semantics treats all counterfactuals with an impossible antecedent as trivially or vacuously true. Many have regarded this as a serious defect of the semantics. For intuitively, it seems, counterfactuals with impossible antecedents—counterpossibles—can be non-trivially true and non-trivially false. Whereas the counterpossible "If Hobbes had squared the circle, then the mathematical community at the time would have been surprised" seems true, "If Hobbes had squared the circle, then sick children in the mountains of Afghanistan at the time would have been thrilled" seems false. Many have proposed to extend the Lewis–Stalnaker semantics with impossible worlds to make room for a non-trivial or non-vacuous treatment of counterpossibles. Roughly, on the extended Lewis–Stalnaker semantics, we evaluate a counterfactual of the form "If A had been true, then C would have been true" by going to closest world—whether possible or impossible—in which A is true and check whether C is also true in that world. If the answer is "yes", the counterfactual is true; otherwise it is false. Since there are impossible worlds in which the mathematically impossible happens, there are impossible worlds in which Hobbes manages to square the circle. And intuitively, in the closest such impossible worlds, sick children in the mountains of Afghanistan are not thrilled—they remain sick and unmoved by the mathematical developments in Europe. If so, the counterpossible "If Hobbes had squared the circle, then sick children in the mountains of Afghanistan at the time would have been thrilled" comes out false, as desired. In this paper, I will critically investigate the extended Lewis–Stalnaker semantics for counterpossibles. I will argue that the standard version of the extended semantics, in which impossible worlds correspond to maximal, logically inconsistent entities, fails to give the correct semantic verdicts for many counterpossibles. In light of the negative arguments, I will then outline a new version of the extended Lewis–Stalnaker semantics that can avoid these problems.     

Indeterminacy and the principle of need

The principle of need—the idea that resources should be allocated according to need—is often invoked in priority setting in the health care sector. In this article, I argue that a reasonable principle of need must be indeterminate, and examine three different ways that this can be dealt with: appendicizing the principle with further principles, imposing determinacy, or empowering decision makers. I argue that need must be conceptualized as a composite property composed of at least two factors: health shortfall and capacity to benefit. When one examines how the different factors relate to each other, one discovers that this is sometimes indeterminate. I illustrate this indeterminacy in this article by applying the small improvement argument. If the relation between the factors are always determinate, the comparative relation changes by a small adjustment. Yet, if two needs are dissimilar but of seemingly equal magnitude, the comparative relation does not change by a small adjustment of one of the factors. I then outline arguments in favor of each of the three strategies for dealing with indeterminacy, but also point out that all strategies have significant shortcomings. More research is needed concerning how to deal with this indeterminacy, and the most promising path seems to be to scrutinize the position of the principle of need among a plurality of relevant principles for priority setting in the health care sector.