Biomedical subjects
Publications and source records attributed to A R Jonsen.
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Referral patterns of physicians have a direct impact upon the care of patients, particularly in obstetrics and gynecology. The choice of referral is influenced by the history of specialization, physician altruism, and intricate patterns of financial conflicts of interest. The conflicts of interest are further obscured by the lack of clear definition of roles and responsibilities for generalist, specialist, and subspecialist. Alternate patterns for referral based on financial incentives or directed referral care plans are reviewed to examine the potential conflicts of interest. An ethics-based format for referral is outlined to address these conflicts of interest.
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This essay focuses on how casuistry can become a useful technique of practical reasoning for the clinical ethicist or ethics consultant. Casuistry is defined, its relationship to rhetorical reasoning and its interpretation of cases, by employing three terms that, while they are not employed by the classical rhetoricians and casuists, conform, in a general way, to the features of their work. Those terms are (1) morphology, (2) taxonomy, (3) kinetics. The morphology of a case reveals the invariant structure of the particular case whatever its contingent features, and also the invariant forms of argument relevant to any case of the same sort: these invariant features can be called topics. Taxonomy situates the instant case in a series of similar cases, allowing the similarities and differences between an instant case and a paradigm case to dictate the moral judgment about the instant case. This judgment is based, not merely on application of an ethical theory or principle, but upon the way in which circumstances and maxims appear in the morphology of the case itself and in comparison with other cases. Kinetics is an understanding of the way in which one case imparts a kind of moral movement to other cases, that is, different and sometimes unprecedented circumstances may move certain marginal or exceptional cases to the level of paradigm cases. In conclusion, casuistry is the exercise of prudential or practical reasoning in recognition of the relationship between maxims, circumstances and topics, as well as the relationship of paradigms to analogous cases.
A large literature treats the ethical issues surrounding communication of health risks. This literature supports the claim that workers have the right to such information and employers the responsibility to provide it. However, the problems arising in particular cases remain difficult to resolve. A "casuistry" of rights and responsibility is suggested, resting on the premise that health information is a common property of all, rather than the particular possession of those who develop it or those who need it.
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The theology of John Calvin has deeply affected the American mentality through two streams of thought, Puritanism and Jansenism. These traditions formulate moral problems in terms of absolute, clear principles and avoid casuistic analysis of moral problems. This approach is designated American moralism. This article suggests that the bioethics movement in the United States was stimulated by the moralistic mentality but that the work of the bioethics has departed from this viewpoint.
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The notion of medical futility has quantitative and qualitative roots that offer a practical approach to its definition and application. Applying these traditions to contemporary medical practice, we propose that when physicians conclude (either through personal experience, experiences shared with colleagues, or consideration of published empiric data) that in the last 100 cases a medical treatment has been useless, they should regard that treatment as futile. If a treatment merely preserves permanent unconsciousness or cannot end dependence on intensive medical care, the treatment should be considered futile. Unlike decision analysis, which defines the expected gain from a treatment by the joint product of probability of success and utility of outcome, our definition of futility treats probability and utility as independent thresholds. Futility should be distinguished from such concepts as theoretical impossibility, such expressions as "uncommon" or "rare," and emotional terms like "hopelessness." In judging futility, physicians must distinguish between an effect, which is limited to some part of the patient's body, and a benefit, which appreciably improves the person as a whole. Treatment that fails to provide the latter, whether or not it achieves the former, is "futile". Although exceptions and cautions should be borne in mind, we submit that physicians can judge a treatment to be futile and are entitled to withhold a procedure on this basis. In these cases, physicians should act in concert with other health care professionals, but need not obtain consent from patients or family members.
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The author describes the comparative dearth of scholarship and literature on medical ethics in 1972 when he began designing an elective lecture-discussion course at the School of Medicine, University of California, San Francisco (UCSF). He traces the development of ethics teaching at that school and of his conviction that medical cases must be the focus of ethics education, not merely as illustrations but as the matrix of the ethical problems encountered and their resolution. Eventually, a required fourth-year course was developed that focused upon four essential aspects of medical cases: medical indications, patient preferences, quality of life, and external socioeconomic factors. This course and its evaluation--including inherent quandaries of evaluating ethics teaching--are described; he attributes the success of the course to the appropriateness of the four-part format for analysis and the support and participation of leading members of the medical faculty. Throughout this description of the UCSF program are short descriptions of the additions to the bioethics literature that were made during the mid- and late 1970s. The author then describes the present ethics teaching program at the University of Washington School of Medicine, where he has taught since 1987, and the intriguing and perhaps innovative possibilities for expanding and redefining that program.
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We present in detail a case of a 27-year-old primigravida who was maintained in a brain-dead state for nine weeks. An apparently normal and healthy male infant weighing 1440 g was delivered. The newborn did well and was found to be growing and developing normally at 18 months of age. Although the technical aspects of prolonged life support are demanding and the economic costs are very high (+217,784), there are ample ethical arguments justifying the separation of brain death and somatic death and the maintenance of the brain-dead mother so that her unborn fetus can develop and mature.
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This discussion was selected from the weekly Grand Rounds in the Department of Medicine, University of Washington School of Medicine, Seattle. Taken from a transcription, it has been edited by Drs Paul G. Ramsey, Associate Professor of Medicine, and Philip J. Fialkow, Professor and Chair of the Department of Medicine.
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