Respect for the developmentally disabled and forgoing life-sustaining treatment

A developmentally disabled person should be treated at all times as a unique individual and not as some anonymous "disabled person." The developmentally disabled should not be subjected to invasive medical treatment that is unduly burdensome or nonbeneficial, or be forced to endure a quality of life not meaningful to them as individuals. They have a right to refuse or accept treatment that a surrogate must exercise on behalf of each individual in a responsible and careful manner. Three cases and a preliminary approach to the ethical analysis of decisions to allow developmentally disabled persons to die by forgoing medical treatment are offered. The "best interests" of a developmentally disabled individual, properly understood, can serve as a useful and ethically defensible standard for determining the ethical propriety of surrogate decision making about forgoing life-sustaining medical treatment of the disabled.     

Ethical dilemas for nurses and their emotional implications

Some of the ethical and emotional problems that are presented to nurses are described. Nurses dealing with them are often the same age as medical students who are just starting their training and on qualifying as doctors will be less experienced in dealing with various life-and-death dilemmas than the nurses looking after their patients. It is contended that despite the fact that almost everyone at some time in their lives is going to depend upon a nurse, the subject of nursing and its dilemmas has been largely neglected, particularly by psychoanalytic/psychotherapy training organisations. Training is described which it is hoped would remedy some of the deficiencies of current nurse-training and encourage personal development and growth. It is also suggested that the training of medical students should include a period of nurse experience and training. The power which can be invested in the nurse is also described, along with the corrupting effect this can have on the nurse/patient relationship.     

Resisting Moral Residue

This paper surveys contemporary scholarly conceptions of moral residue in order to demonstrate the fruitful inconsistencies contained in these various notions. Due to the fact that moral dilemmas are commonplace in the practice of medicine, patients and practitioners are uniquely situated to experience moral residue. The authors investigate two medical sites as case studies that demonstrate how a more capacious notion of moral residue can be useful for explaining ethical complexities: euthanasia on the battlefield and care of minors who are members of the Jehovah’s Witness faith community. These case studies will be of particular interest to chaplains, pastoral theologians, and other relevant practitioners and intellectuals. Fruitfully cast against the illuminations of interdisciplinary scholars including Donald Capps, Lorraine Hardingham, and others, these cases are used as instructive discursive devices, shedding greater light on ideas put forth within the literature on this engaging and complex topic.     

The futures of physicians: Agency and autonomy reconsidered

The corporatization of U.S. health care has directed cost containment efforts toward scrutinizing the clinical decisions of physicians. This stimulated a variety of new utilization management interventions, particularly in hospital and managed care settings. Recent changes in fee-for-service medicine and physicians' traditional agency relationships with patients, purchasers, and insurers are examined here. New information systems monitoring of physician ordering behavior has already begun to impact on physician autonomy and the relationship of physicians to provider organizations in both for-profit and ‘not-for-profit’ sectors. As managed care practice settings proliferate, serious ethical questions will be raised about agency relationships with patients. This article examines health system dynamics altering the historical agency relationship between the physician and patient and eroding the traditional autonomy of the medical profession in the United States. The corporatization of medicine and the accompanying information systems monitoring of physician productivity is seen to account of such change, now posing serious ethical dilemmas.     

Medical education: The training of ethical physicians

This paper suggests that medical education be revised to assist in diffusing potential ethical dilemmas that arise during health care provision. A revised medical education would emphasize the role of the humanities in the training of physicians, especially in light of recent critiques of the canonical scientific model in general, and more specifically in the use of that model for medical training and practice.I wish to thank Dr. Mary Ann Cutter and Melissa M. Amaro for their critical suggestions.     

美国与知情同意有关的一些问题

知情同意是医疗保健和医学研究的一个基本的伦理学要求。这两种情况中,当医学研究的知情同意标准比医疗保健要求更加严格时,知情同意包含了3种要素：（1）告知病人或受试者该研究的性质。包括益处,危险和其他有关内容;（2）确保病人受试者理解所提供的信息;（3）得到病人或受试者自愿的同意,没有能力参与知情同意的病人包括患痴呆和危重病等无决断 能力的病人,这些病人属弱势病人。如要获许对他们的疾病进行研究,我们必须制定保护弱势受试者有效的伦理政策,提出了关于对痴呆病人、危重病人,脑死亡病人研究的伦理学政策。     

Complexity of ethical decision making in psychiatry

Psychiatric residents and psychiatrists have little difficulty in making judgments about a clinical course of action to take with patients. However, making ethical clinical decisions is more challenging, because psychiatric residents are usually provided little formal training in ethics. Further, many ethical dilemmas are complex, requiring knowledge of the psychiatric profession's ethics code, moral principles, law, and practice standards and of how they should be weighed in the decision-making process. The purpose of this article is to demonstrate this complexity in regard to the identification of potential ethical dilemmas, understanding the issues that these dilemmas raise, and formulating potential solutions to them. Two common but important areas of treatment in which ethical dilemmas arise (informed consent and competence of care) are used as examples for our presentation. The article demonstrates that to successfully engage in ethical analysis in psychiatry is impossible without substantial formal training in the process.     

Genetic Counseling for the Orthodox Jewish Couple Undergoing Preimplantation Genetic Diagnosis

Orthodox Jewish patients who seek genetic counseling are often placed in a difficult position of having to choose between their desire to follow Jewish religious instruction (halacha) and following the advice of the genetic counselor. In this article we will present the work of the Puah Institute based in Jerusalem that is dedicated to assisting and guiding such couples to navigate through the medical system and medical recommendations and create a harmony between modern genetic counseling and the Orthodox Jewish tradition. In light of the expanding use of preimplantation genetic diagnosis (PGD) for a variety of medical and non-medical conditions, this dilemma is even more poignant. There is an ethical debate regarding PGD and the correct parameters for its use. Here we present the Orthodox Jewish view of the use and abuse of PGD. We present three case studies that sought the assistance and guidance of the Puah Institute. Each of these cases raises ethical dilemmas for the genetic counselor and for the rabbinic counselor. We discuss; the status of the embryo, the status of a carrier of a genetic abnormality and whether PGD is an obligation or good practice. In addition we deal with whether PGD and the search for the desired traits can be defined as eugenics or not.     

THE DUTY TO FEED IN CASES OF ADVANCED DEMENTIA

Cases of dementia present us with difficult ethical dilemmas as we strive to care for those unable to care for themselves. In this article, I review the relevant Islamic texts on caring for the ill, alleviating suffering, and feeding the hungry—all in light of the modern clinical environment. I find that the ethical appropriateness of tube feeding at the end of life is not as clear‐cut as it may seem. My analysis, however, suggests that Muslim scholars ought to favor insertion of a feeding tube in patients who can no longer respond to assisted feeding. Nonetheless, several important issues require further clarification in this clinically important but neglected area of ethical inquiry.     

The right to practice medicine without repercussions: ethical issues in times of political strife

ABSTRACT: This commentary examines the incursion on the neutrality of medical personnel now taking place as part of the human rights crises in Bahrain and Syria, and the ethical dilemmas which these incursions place not only in front of physicians practicing in those nations, but in front of the international community as a whole.In Bahrain, physicians have recently received harsh prison terms, apparently for treating demonstrators who clashed with government forces. In Syria, physicians are under the same political pressure to avoid treating political demonstrators or to act as informants against their own patients, turning them in to government authorities. This pressure has been severe, to the point that some physicians have become complicit in the abuse of patients who were also political demonstrators.This paper posits that physicians in certain countries in the Middle East during the "Arab Spring," specifically Syria and Bahrain, are being used as both political pawns and political weapons in clear violation of Geneva Convention and World Medical Association guidelines, and that this puts them into the most extreme sort of "dual loyalty" dilemma. They are being forced to choose between their own safety and well-being and that of their patients -- a negative sum scenario wherein there is no optimal choice. As such, an international call for a United Nations inquiry must be made in order to protect the neutrality of medical care and personnel during times of armed conflict.     

INTELLECTUAL DISABILITY AND MYSTICAL UNKNOWING: CONTEMPORARY INSIGHTS FROM MEDIEVAL SOURCES

Intellectual disabilities make people vulnerable to marginalization in churches and social spaces, but theology has not sufficiently attended to the topic and promoted the flourishing of people who have cognitive impairments. This article responds to theology's inadequate attention to intellectual disability and historical resources for reflection on the topic by reading medieval sources with intellectual disability in mind. I argue that Bonaventure's Itinerarium Mentis in Deum provides a model for imagining intellectually disabled and nondisabled people sharing the journey into God and that Eckhart's view of intellect as the uncreated element in the soul includes people who are intellectually disabled among those who may be united with God.     

The practice of psychology in rural communities: potential ethical dilemmas

The practice of psychology in rural areas offers unique challenges for psychologists as they try to provide optimal care, often with a minimum of resources. Psychologists are frequently required to be creative and flexible in order to provide effective services to a wide range of clients. However, these unique challenges often confront psychologists with ethical dilemmas and problems for which their urban-based training has not prepared them. The author examines how certain characteristics of rural communities may lead to specific ethical dilemmas. By being a part of a small community, psychologists will inevitably face multiple relationship dilemmas. Confidentiality is harder to maintain in a small town, particularly with its informal information-sharing network. To provide services to meet community needs, with a limited number of referral options, psychologists typically need to be generalists. This may lead to concerns about scope of practice, training, and experience with diverse populations. Psychologists also face other competency issues, such as a lack of supervision and consultation resources. Other concerns addressed include the psychologist's personal life, and the blurring of professional and personal roles. Suggestions are made for coping with each of these ethical issues, although more quantitative research and discussion are needed on the practice of psychology in rural areas.     

Ethical implications in the allocation of scarce medical resources in Poland

The health care system in Poland is undergoing major change and it is possible that these changes could affect clinical research. Therefore, the situation of funding of health care is important for the future of medical research in this country. Some questions relevant in this field will be addressed. Since funds for health care and scientific research remain inadequate, their allocation raises moral, economic, legal and organisational dilemmas. The clinical aspects of resource allocation also include physicians’ responsibilities towards their patients. Scientific research, clinical medicine, and clinical research have a common denominator: they rely on trust. The physician should be a fiduciary of the patient as well as being a researcher for the benefit of the patient and for society. Some physicians and researchers, despite unethical conduct, escape disclosure and punishment, but decision-makers who wrongly allocate funds for health care and research are never held accountable for their actions. An earlier version of this paper was presented at a symposium, Scientific Misconduct: An International Perspective, organised by The Medical University of Warsaw, 16 November, 1998.     

Considerations for ethical practice in managed care

How does one maintain an ethical practice while facing the requirements and limits of a health care system that is dominated by managed care? Psychologists are increasingly raising such questions about ethical issues when working in or contracting with managed care organizations. The authors review the process involved in ethical decision making and problem solving and focus on 4 areas in which ethical dilemmas most commonly arise in a managed care context: informed consent, confidentiality, abandonment, and utilization management-utilization review. The need for sustained and organized advocacy efforts to ensure patient access to quality health care is discussed, as is the impact of managed care's competitive marketplace on professional relationships. Hypothetical examples of typical dilemmas psychologists face in the current practice environment are provided to illustrate systematic ethical decision making.     

Newsworthy Moral Dilemmas: Justice,Caring, and Gender

Gilligan (1982) put forth a care moralorientation based on women's responses to moraldilemmas. We tested in 2 studies Gilligan's predictedgender differences and the effect of dilemma content onmoral orientation. We used real-life dilemmasconsisting of the Baby M surrogate motherhood case andthe Kimberly Mays case where babies were switched atbirth;these dilemmas had the advantage of beingstandardized across all participants, and of being moreinvolving than hypothetical dilemmas. The Baby M dilemmaelicited primarily justice responses while the KimberlyMays case elicited care responses; yet in both these dilemmas, when compared to men, womenscored higher on care, and lower on justice.Additionally, moral orientation was related to specificresolutions ofthe dilemmas.Thus both genders wereflexible in their use of justice and care orientationsdepending on the dilemma, with gender differences stillapparent within dilemmas.     

Responses of School Psychologists and Special Education Teachers to Administrative Pressures to Practice Unethically

Abstract

Responses of school psychologists (N = 141) and special educators (N = 130) to ethical dilemmas involving conflicts between administrative directives and ethical obligations were examined. Respondents completed a survey asking them to predict their own and others' responses to four ethical dilemmas. The majority of respondents predicted that they, immediate colleagues, and professional peers would make the choices judged as ethical in all situations. Predictions of ethical response were highest for self prediction and varied across the four dilemmas. Respondents who viewed their immediate colleagues as supportive of autonomous decision making were more likely to predict ethical choices than those who viewed their colleagues as supporting deference to administrative authority. No differences in predictions related to gender, degree level, job security, preservice training in or knowledge of professional ethics or special education law were found.     

Ethics and Changing Mental Health Care: Concerns and Recommendations for Practice

Recent developments in health care delivery in the United States have left many professionals baffled by the continuing changes in practice sparked by the relatively new managed care environment. Psychologists who practice in medical settings are struggling to balance the seemingly competing needs to deliver quality care to clients and patients, while meeting the demands of third-party payers and trying to remain true to their ethical responsibilities. Critical elements of managed care, which many suggest compromise the ethical provision of quality care, include utilization review, financial incentives, and threats to confidentiality. Recommendations are proposed so that mental health professionals may be proactive in protecting their ethical responsibilities in this changing environment.     

Sufficiency of care in disasters: ventilation, ventilator triage, and the misconception of guideline-driven treatment

This essay examines the management of ventilatory failure in disaster settings where clinical needs overwhelm available resources. An ethically defensible approach in such settings will adopt a "sufficiency of care" perspective that is: (1) adaptive, (2) resource-driven, and (3) responsive to the values of populations being served. Detailed, generic, antecedently written guidelines for "ventilator triage" or other management issues typically are of limited value, and may even impede ethical disaster response if they result in rescuers' clumsily interpreting events through the lens of the guideline, rather than customizing tactics to the actual context. Especially concerning is the tendency of some expert planners to mistakenly assume that medical treatment of respiratory failure: (1) always requires full-feature mechanical ventilators, (2) will always occur in hospitals, and (3) can be planned in advance without sophisticated public consultation about likely ethical dilemmas.     

Queer Patients and the Health Care Professional—Regulatory Arrangements Matter

This paper discusses a number of critical ethical problems that arise in interactions between queer patients and health care professionals attending them. Using real-world examples, we discuss the very practical problems queer patients often face in the clinic. Health care professionals face conflicts in societies that criminalise same sex relationships. We also analyse the question of what ought to be done to confront health care professionals who propagate falsehoods about homosexuality in the public domain. These health care professionals are more often than not motivated by strong religious convictions that conflict with mainstream medical opinion on homosexuality. We argue that they ought to be held accountable for their conduct by their professional statutory bodies, given that they abuse their professional standing to propagate sectarian views not representative of their profession. Lastly, we propose that medical schools have special responsibilities in training future health care professionals that will enable them to respond professionally to queer patients seeking health care.     

Genetics and the Interpersonal Elaboration of Ethics

Confidentiality in genetic testing posesimportant ethical challenges to the currentprimacy of respect for autonomy and patientchoice in health care. It also presents achallenge to approaches to decision-makingemphasising the ethical importance of theconsequences of health care decisions. In thispaper a case is described in which respect forconfidentiality calls both for disclosure andnon-disclosure, and in which respect forpatient autonomy and the demand to avoidcausing harm each appear to call both fortesting without consent, and testing only withconsent. This creates problems not only forclinicians, families and patients, but also forthose who propose clinical bioethics as a toolfor the resolution of such dilemmas.In this paper I propose some practical waysin which ethical issues in clinical geneticsand elsewhere, might be addressed. Inparticular I call for a closer relationshipbetween ethics and communication in health caredecision-making and describe an approach to theethics consultation that places particularemphasis on the value of interpersonaldeliberation in the search for moralunderstanding. I reach these conclusionsthrough an analysis of the concept of `moraldevelopment' in which I argue that theachievement of moral understanding is anecessarily intersubjective project elaboratedby moral persons.