1994
J. Boyle
- Abstract: This paper addresses the moral challenges
presented by the existence of radical moral disagreement in contemporary
health care. I argue that there is no neutral moral perspective for
understanding and resolving these challenges, but that they must be
formulated and resolved from within the various perspectives that generate
the disagreement. I then explore the natural law tradition's approach to
these issues as a test case for my thesis.
Callahan D. Bioethics:
Private choice and common
good.
Hastings Cent Rep 1994 May-June; 24(3):31.
Daniel Callahan
- Almost from its start bioethics has been a child of its time, and a
child of good fortune at that. In his 1954 book Medicine and Morals,
Joseph Fletcher ventured the idea of personal choice as the highest
moral value and the struggle against nature as medicine's most
liberating mission. That was a bold combination at the time, but it
turned out to have been prophetically popular, and by the late 1960s its
force was becoming apparent not only in medicine but in the fledgling
field of bioethics. Fletcher's grand themes needed only to be
complemented by another great theme of the times, justice and
equality, to catch fully that era in midflight. . .
Leslie Cannold
- The legitimacy of the refusal of South Australian nurses to care for
second trimester abortion patients on grounds of conscience is examined
as a test case for a theory of permissible limits on the autonomy of
health care professionals. In cases of health care professional (HCP)
conscientious refusal, it is argued that a balance be struck between the
HCPs' claims to autonomous action and the consequences to them of having
their autonomous action restricted, and the entitlement of patients to
care and the consequences for them of being refused such care.
Conscientious action that results in the disruption or termination of
health care services, however, is always impermissible on two grounds.
Firstly, because it is at this point that the action '... invades a
patient's autonomy, puts a patient at serious risk ... [and] treats a
patient unjustly' (1) Secondly, because the consequences of such refusals
turn them into political acts - acts of civil disobedience. It is
arguable that in order for acts of civil disobedience to be
legitimate, certain obligations are required of the dissenter by the
community. It is concluded that the actions of the South Australian
nurses, which have over the last few years both terminated and disrupted
second trimester services, are morally impermissible.
Anna Maria Cugliari, Tracy E. Miller
- Abstract: A patient's right to decide about
life-sustaining treatment may conflict with the policies of health care
facilities that refuse on the basis or religious or moral convictions to
honor certain decisions to forgo treatment. The New York State Task Force
on Life and the Law examined the prevalence and nature of facility
conscience objections to the refusal of life-sustaining treatment by
conducting a survey of New York hospitals. Written questionnaires were
distributed to hospitals in New York State. Fifty-eight percent of the
New York State hospitals responded. Twenty-nine percent of the
respondents indicated that their hospital would object on grounds of
conscience either to withholding or to withdrawing life-sustaining
treatment in at least one of the twelve hypothetical cases presented.
Hospitals were more likely to have "no policy" for withdrawing than tbr
withholding treatment. Only 10% of the hospitals that would object to
decisions to forgo treatment on religious or moral grounds had stated the
objections in writing. The patient's medical condition and the type of
life-sustaining treatment to be withdrawn or withheld are important
factors in determining whether a hospital will object on grounds of
conscience. The imminence of death appeared more decisive than the degree
of debilitation or disability as a factor in the willingness to accept
decisions to forgo life-sustaining treatment. Hospitals should establish
clear, written policies about their objections to forgoing treatment so
that patients and their families can evaluate whether the facility meets
their needs.
Denstedt-Stigzelius I. [The right to have a conscience]
Lakartidningen 1994 Jun 22;91(25):2491 (Letter)
[Article in Swedish] PMID: 8046956
I. Denstedt-Stigzelius
Dooley D.
Conscientious refusal to assist with abortion.
BMJ 1994 Sep 10;309(6955):622-3 (Editorial) [Comment in: BMJ. 1994 Dec
10;309(6968):1582.] PMID: 8086982
Dolores Dooley
- Claims of conscience by doctors and nurses almost always relate to
substantial moral issues that touch closely on their identity and
integrity. Abortion is such an issue. Agreement among reasonable and
sincere individuals often seems beyond reach. Ethical reasoning promises
no conclusive resolution but might constructively help us to
understand the sources of disagreement and search for shared principles
in the differences. . .
Rebecca S. Dresser
- Acess to abortion is becoming increasingly restricted for many women in
the United States. Besides the longstanding financial barriers facing
low-income women in most states, a newer source of scar city has emerged.
The relatively small number of physicians willing to perform the
procedure is compromising the ability of women in certain parts of the
country to obtain an abortion. Do physicians have a duty to respond to
this situation? Do they have a professional responsibility to ensure
that abortions are reasonably available to the women who want to terminate
their pregnancies? Or, is abortion so morally and socially controversial
as to remove any professional obligation to provide reasonable access?
Christopher L. Eisgruber, Lawrence G. Sager
- In Employment Division, Department of Human Resources of Oregon v Smith,
the Supreme Court held that members of the Native American Church were not
constitutionally entitled to ingest peyote as part of their religion's
sacrament in the face of an Oregon law outlawing the use of peyote. Many
aspects of the Smith decision have been sharply criticized, but none so much
as the general view of religious exemptions announced by Justice Scalia's
opinion for the Court. Justice Scalia distinguished freedom of religious
belief from behavior driven by religious belief, and further distinguished
laws directed at religion from general laws that merely collide with
behavior driven by religious belief. That work done, Justice Scalia had a
simple and flat response to the constitutional claimants in Smith: religious
believers have no constitutional license to disregard otherwise-valid
general laws that conflict with the dictates of their religion. . .
N.T. Enheten
Frederick W. Hafferty, Ronald Franks
- Abstract: The authors raise
questions regarding the wide-spread calls emanating from lay and medical
audiences alike to intensify the formal teaching of ethics within the
medical school curriculum. In particular, they challenge a prevailing belief
within the culture of medicine that while it may be possible to teach
information about ethics (e.g., skills in recognizing the presence of common
ethical problems, skills in ethical reasoning, or improved understanding of
the language and concepts of ethics), course material or even an entire
curriculum can in no way decisively influence a student's personality or
ensure ethical conduct. To this end, several issues are explored, including
whether medical ethics is best framed as a body of knowledge and skills or
as part of one's professional identity. The authors argue that most of the
critical determinants of physician identity operate not within the formal
curriculum but in a more subtle, less officially recognized "hidden
curriculum." The overall process of medical education is presented as a form
of moral training of which formal instruction in ethics constitutes only one
small piece. Finally, the authors maintain that any attempt to develop a
comprehensive ethics curriculum must acknowledge the broader cultural milieu
within which that curriculum must function. In conclusion, they offer
recommendations on how an ethics curriculum might be more fruitfully
structured to become a seamless part of the training process.
Sylvia A. Law
- Introduction: More than half of the pregnancies among
American women are unintended, and half of these are terminated by
abortions; in 1988, 1.6 million abortions were performed in the United
States. Often, a woman is informed by a physician or other health care
provider that she is pregnant. This Article explores the ethical and
medical principles that should guide physicians and other health care
providers in conversations that follow the confirmation of pregnancy. It
argues that physicians should not automatically assume that a pregnant
woman wants to continue or end the pregnancy. Rather, the doctor should
ask the woman what her reaction is to the news that she is pregnant, and
provide medical information informing the patient of her choices. The
physician should then refer her to those appropriate medical services
that he or she does not personally provide. . .
K. Nyman
Pellegrino ED. Patient and physician autonomy:
conflicting rights and obligations in the physician patient relationship. 10
J. Contemp. Health L. & Pol'y 47 1994
Edmund D. Pellegrino
- For centuries, physician beneficence went unchallenged as the first
principle of medical ethics. To be sure, some physicians had, at times,
violated this principle. But no creditable ethical opposition was mounted
until a quarter of a century ago when patient autonomy was asserted as a
prima facie moral principle of equal or greater weight than beneficence.'
Progressively since then, patient autonomy has become the dominant
principle shaping physician-patient relationships.
Three serious moral conflicts have emerged as a result: first,
beneficence and autonomy have been polarized against each other when they
should be complementary; second, the physician's moral claim to autonomy
has received little attention; and third, the "autonomy" of medical
ethics, itself, has come under a serious threat. This essay will examine
each of these three consequences resulting from the rise of patient
autonomy. . .
S. Wear, S. Lagaipa, G. Logue
- Abstract: The removal of life-sustaining treatment often
brings physicians into conflict with patients. Because of their moral
beliefs physicians often respond slowly to the request of patients or their
families. People in bioethics have been quick to recommend that in cases of
conflict the physician should simply sign off the case and "step aside".
This is not easily done psychologically or morally. Such a resolution also
masks a number of more subtle, quite trouble some problems that conflict
with the commitment to toleration and moral diversity that it is intended to
support. These conflicts are detailed and evaluated.