The rationing of health care: A doctor's dilemma

Physicians are currently presented with very difficult ethical issues regarding who receives what level of medical care and for how long. A meaningful response to these perplexing issues necessitates a collaboration of doctors with others steeped in religious and ethical traditions. This paper addresses the complicated issue of the rationing of health care, and this issue is then addressed by responses from representatives of the religious community. This symposium took place at the New York Hospital—Cornell Medical Center in March 1991.The Rev. Curtis W. Hart, M.Div. is Director of Pastoral Care and Education at the New York Hospital—Cornell Medical Center.The Rev. Paul Conner, O.P., is Associate Professor and Director of the Master's Program in Public Health Care Ethics at New York Medical College. Larry Rasmussen, Th.D., is Reinhold Niebuhr Professor of Social Ethics at Union Theological Seminary in New York. Dr. Harlan J. Wechsler is Rabbi of Congregation Or Zarua and Visiting Professor of Philosophy at Jewish Theological Seminary in New York.     

Inhibition of the LH Surge by Restraint Stress in Cyclic Rats: Studies on the Role of GABAA and GABAB Receptors

There is evidence that stress can alter the activity in the brain of gamma-aminobutyricacid (GABA), a neurotransmitter that has been implicated in the regulation of LH secretion. In the present study the role of GABA in the restraint stress-induced inhibition of the LH surge was investigated in the intact cyclic rat. Intracerebroventricular (icv) administration of the GABAA receptor agonist muscimol (0.1, 0.5 or 1 μg) 5 min before the presumed onset of the pro-oestrous LH surge (at 0900 h) caused a dose dependent suppression of the surge. A single dose of the GABAB receptor agonist baclofen (1 μg; icv) injected at 0855 h postponed the onset of the LH surge, and repeated injections at 0855 and 1130 h suppressed the surge. These data indicate that GABA-ergic activity in the brain can inhibit the LH surge in the cyclic rat via GABAA and GABAB receptors. Pro-oestrous rats were subjected to 5 hrs of restraint starting at 0855 h. Pretreatment with the GABAA receptor antagonist bicuculine (1 μg; icv) at 0840, 0940 and 1040 h or pretreatment with the GABAB receptor antagonist phaclofen (10 μg; icv) at 0840 h were ineffective in preventing the restraint-induced inhibition of the LH surge. The results suggest that GABAA and GABAB receptors are not involved in the inhibitory effect of restraint stress on the LH surge.     

Clinical pragmatism: a method of moral problem solving

This paper presents a method of moral problem solving in clinical practice that is inspired by the philosophy of John Dewey. This method, called "clinical pragmatism," integrates clinical and ethical decision making. Clinical pragmatism focuses on the interpersonal processes of assessment and consensus formation as well as the ethical analysis of relevant moral considerations. The steps in this method are delineated and then illustrated through a detailed case study. The implications of clinical pragmatism for the use of principles in moral problem solving are discussed.     

Clinical pragmatism: bridging theory and practice

This response to Lynn Jansen's critique of clinical pragmatism concentrates on two themes: (1) contrasting approaches to moral epistemology and (2) the connection between theory and practice in clinical ethics. Particular attention is paid to the status of principles and the role of consensus, with some closing speculations on how Dewey might view the current state of bioethics.     

Across the divide: Religious objections to brain death

This article reviews the evolution of the medical-legal definition of brain death, as well as the normative debate surrounding this reconceptualization. It offers a clinical approach to address religious objections to brain death, which prefers negotiation over confrontation when families and practicitioners must discern the boundaries between life and death.He also serves as physician-ethicist-in-residence at the Hospital Chaplaincy in New York City. An earlier draft of this essay was presented to the Metropolitan New York Ethics Committee Network at the New York Academy of Medicine on 16 November 1994.     

Enrolling decisionally incapacitated subjects in neuropsychiatric research

This paper discusses the National Bioethics Advisory Commission's (NBAC's) report on research involving persons with mental disorders that may affect decisionmaking capacity. After placing the NBAC recommendations into their historic context, the authors propose a strategy to enroll decisionally incapacitated subjects into neuropsychiatric research. The authors maintained that their proposed consensus model for research authorization, utilizing subject advocates, fosters valuable clinical research while protecting potentially vulnerable subjects.     

A Pilot Evaluation of Portfolios for Quality Attestation of Clinical Ethics Consultants

Although clinical ethics consultation is a high-stakes endeavor with an increasing prominence in health care systems, progress in developing standards for quality is challenging. In this article, we describe the results of a pilot project utilizing portfolios as an evaluation tool. We found that this approach is feasible and resulted in a reasonably wide distribution of scores among the 23 submitted portfolios that we evaluated. We discuss limitations and implications of these results, and suggest that this is a significant step on the pathway to an eventual certification process for clinical ethics consultants.