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PubMed2005

Is there any solution to the "brain drain" of health professionals and knowledge from Africa?

African public health care systems suffer from significant "brain drain" of its health care professionals and knowledge as health workers migrate to wealthier countries such as Australia, Canada, USA, and the United Kingdom. Knowledge generated on the continent is not readily accessible to potential users on the continent. In this paper, the brain drain is defined as both a loss of health workers (hard brain drain) and unavailability of research results to users in Africa (soft brain drain). The "pull" factors of "hard brain drain" include better remuneration and working conditions, possible job satisfaction, and prospects for further education, whereas the "push" factors include a lack of better working conditions including promotion opportunities and career advancement. There is also a lack of essential equipment and non-availability or limited availability of specialist training programs on the continent. The causes of "soft brain drain" include lack of visibility of research results in African journals, better prospects for promotion in academic medicine when a publication has occurred in a northern high impact journal, and probably a cultural limitation because many things of foreign origin are considered superior. Advocates are increasingly discussing not just the pull factors but also the "grab" factors emanating from the developed nations. In order to control or manage the outflow of vital human resources from the developing nations to the developed ones, various possible solutions have been discussed. The moral regard to this issue cannot be under-recognized. However, the dilemma is how to balance personal autonomy, right to economic prosperity, right to personal professional development, and the expectations of the public in relation to adequate public health care services in the developing nations.

Africa↗

PubMedDate not supplied

Cancer patients' perceptions of do not resuscitate orders.

Patients' perceptions of do not resuscitate (DNR) orders and how and when to present the information were sought to aid in framing DNR policy. Semi-structured interviews of 23 patients being treated for cancer, were conducted by a clinical psychologist. The interviews were transcribed and analysed with the aid of a qualitative software package. Discourse analysis enabled hypotheses to be formed based on consistencies and variations of the language used. Most patients understood what DNR meant and preferred DNR orders to 'good palliative care' orders. They saw it as their autonomous right and responsibility to make such decisions. They would seek information on the likely medical outcomes of resuscitation but also would use non-rational criteria based on emotional and social factors to make their decisions. Family considerations suggest that personal autonomy is not the overriding basis of the decision. Patients were unsure of the best timing of a DNR discussion and were prepared to defer to doctors' intuition. Most advocated written DNR orders but few had them. Families were construed as advocates but also seen as constraining individual autonomy. When considering DNR orders, patients recognise the diversity of preferences likely to exist that belie a one policy fits all approach.

Family↗

PubMed1999

Genetic privacy: orthodoxy or oxymoron?

In this paper we question whether the concept of "genetic privacy" is a contradiction in terms. And, if so, whether the implications of such a conclusion, inevitably impact on how society comes to perceive privacy and responsibility generally. Current law and ethical discourse place a high value on self-determination and the rights of individuals. In the medical sphere, the recognition of patient "rights" has resulted in health professionals being given clear duties of candour and frankness. Dilemmas arise, however, when patients decline to know relevant information or, knowing it, refuse to share it with others who may also need to know. This paper considers the notions of interconnectedness and responsibility to others which are brought to the fore in the genetic sphere and which challenge the primacy afforded to personal autonomy. It also explores the extent to which an individual's perceived moral obligations can or should be enforced.

Beneficence↗

PubMedDate not supplied

Resident smoking in long-term care facilities--policies and ethics.

OBJECTIVE: To characterize smoking behavior, facility policies related smoking, and administrators' views of smoking-related problems in Veterans Affairs nursing home care units nationwide. METHODS: An anonymous mail survey of long-term care facilities was administered to 106 nursing home supervisors at VA Medical Centers with nursing home care units. The response rate was 82%. RESULTS: Administrators from 106 VA nursing home units reported smoking rates ranging from 5% to 80% of long-term care residents, with an average of 22%. Half of the nursing homes had indoor smoking areas. Frequent complaints from nonsmokers about passive smoke exposure were reported in 23% of the nursing homes. The nursing administrators reported that patient safety was their greatest concern. Seventy- eight percent ranked health effects to the smokers themselves a "major concern," while 70% put health effects to exposed nonsmokers in that category. Smoking in the nursing home was described as a "right" by 59% of respondents and a "privilege" by 67%. Some individuals reported that smoking was both a right and a privilege. CONCLUSION: Smoking is relatively common among VA long-term care patients. The promotion of personal autonomy and individual resident rights stressed in the Omnibus Budget Reconciliation Act of 1987 may conflict with administrative concerns about the safety of nursing home smokers and those around them.

Aged↗

PubMed2000

Death--whose decision? Euthanasia and the terminally ill.

In Australia and Oregon, USA, legislation to permit statutory sanctioned physician-assisted dying was enacted. However, opponents, many of whom held strong religious views, were successful with repeal in Australia. Similar opposition in Oregon was formidable, but ultimately lost in a 60-40% vote reaffirming physician-assisted dying. This paper examines the human dilemma which arises when technological advances in end-of-life medicine conflict with traditional and religious sanctity-of-life values. Society places high value on personal autonomy, particularly in the United States. We compare the potential for inherent contradictions and arbitrary decisions where patient autonomy is either permitted or forbidden. The broader implications for human experience resulting from new legislation in both Australia and Oregon are discussed. We conclude that allowing autonomy for the terminally ill, within circumscribed options, results in fewer ethical contradictions and greater preservation of dignity.

Attitude of Health Personnel↗

PubMed1991

Treating fetuses: the patient as person.

The medical treatment in utero of human beings raises several ethical questions. I argue that treatment is sufficient to establish the fetus as person; and consider how conflicts between the interests of the fetus and mother are to be resolved when such treatment is proposed. My arguments rest upon a 'relational model' of ethical discourse derived from H. Richard Niebuhr's "ethics of the fitting." I conclude that the limitation of personal autonomy is rarely justified, but may be when direct, grave, harm to others is imminent; and that educative rather than punitive measures are the best prospect for protecting fetal life.

Beginning of Human Life↗

PubMed2003

Informed consent without bureaucracy.

A comparison is drawn between informed consent in medicine and consenting practices in other areas of human activity, and an underlying conceptual unity is detected in all of these consenting practices. We insist on obtaining consent, in medicine and elsewhere, because of the value we place on personal autonomy. The conceptual unity of informed consent and consenting practices outside of medicine is defended against a series of objections. On the basis of the comparison with consenting practices in other areas of human activity, it is argued that bureaucratic informed consent processes in medicine are both unnecessary and unwarranted.

Disclosure↗

PubMedDate not supplied

Home is where their wheels are: experiences of women wheelchair users.

This paper examines the experiences of mothers who are wheelchair users in their roles of homemaking and parenting. A qualitative study using in-depth, focused interviews was conducted with a purposeful sample of 11 women with various physical disabilities. Three major themes were uncovered in the data: (a) lived space restricting personal autonomy, (b) advocacy strategies to secure appropriate housing, and (c) my wheelchair, my liberator, my sense of comfort. Findings from this study showed that women did not have the freedom or economic resources to seek out new living arrangements or make modifications to existing environments. Lack of space, stairs, difficult-to-reach spaces, poor transportation, and limited community access were barriers that women experienced. The study also points to the importance of recognizing that the women used many strategies to regain control over aspects of their environment to enable greater autonomy and participation for themselves. Sensitivity to the meaning of home and the relationship between the body and the environmental features that surround it may be a significant contribution of the clinician as he or she seeks to assist women wheelchair users.

Activities of Daily Living↗

PubMed1994

Medical experimentation, informed consent and using people.

In this paper we argue that the standard focus on problems of informed consent in debates about the ethics of human experimentation is inadequate because it fails to capture a more fundamental way in which such experiments may be wrong. Taking clinical trials as our case in point, we suggest that it is the moral offence of using people as mere means which better characterizes what is wrong with violations of personal autonomy in certain kinds of clinical trials. This account also helps bring out another important way in which the autonomy of the participants in clinical trials may be violated, even in cases where they have given informed consent to their involvement. Where relevant information about the trial is framed in such a way as to induce a patient's participation by appeal to their nonrational preferences, this is also a violation of their autonomy, and one which is distinct from a failure of informed consent. The underlying wrongness of both kinds of violations, we argue, is plausibly captured by the moral offence of using people as mere means.

Coercion↗

PubMed1985

Oregon Health Decisions. An experiment with informed community consent.

Oregon Health Decisions is a citizen-based project intended to develop statewide awareness of severe bioethical dilemmas. The project has set in motion civic means for addressing and resolving problems in Oregon's health provision system associated with personal autonomy, equity of access, prevention of illness, and humane cost containment. The process of civic involvement with consequent results is described together with the implications for future health policy in Oregon and elsewhere.

Advisory Committees↗

PubMed2006

Rewriting the competency rules for children: full recognition of the young person as rights-bearer.

The rules regarding the competency of children to consent to medical treatment have traditionally focused on the child's understanding of the proposed treatment. This article argues that this focus has perpetuated an unjustifiably paternalistic attitude to the treatment of children that is inconsistent with obligations under the Convention on the Rights of the Child and the common law's preference for upholding personal autonomy. A new test is therefore proposed, abandoning the presumption of incompetency for adolescents and focusing on the understanding of the right to make medical decisions. The application of the proposed test is examined both from a general point of view and with regard to a particularly vulnerable group of young people: those suffering from mental illness.

Adolescent↗

PubMed2006

Genetic testing of children for adult-onset diseases: is testing in the child's best interests?

Questions related to testing children for adult-onset genetic diseases include many variables that generate different answers among different families. These issues include the biological nature of specific genes, concern about what benefits or harms may accrue from testing children, possible psychosocial sequelae, and ethical and legal concerns about personal autonomy. The shift in the physician-patient relationship from professional beneficence to patient autonomy has established the patient, or parents, as the primary decision-makers in questions about treatment or testing options. The role of parents as decision-makers for their own minor children has been reinforced by four seminal holdings of the United States Supreme Court. Assertions about protecting the future autonomy of children are invalid because minor children are not autonomous. Their parents, on the other hand, have a right--and perhaps even a duty--to exercise their own vested autonomy in making decisions that they believe are in the best interests of their own families. Geneticists are urged to provide clear and complete counseling to parents who seek testing for their children, and then defer to the parents as the primary decision-makers for their own minor children.

Adult↗

PubMed1983

Processes in the formulation and legitimisation of professional ethics in a changing world.

Within any given profession two sorts of moral problems arise: 'general' problems which are solvable by universal moral considerations, and 'role-specific' problems, which are generated or solved by norms unique to the profession. It is role-specific norms which are theoretically significant to professional ethics. This essay begins an investigation of role-specific norms for medical ethics, concentrating in particular upon the traditional claim that a physician's primary duty is the restoration and preservation of a patient's health. This norm is derivable from the concept of medicine itself, and can be defended against contemporary sceptical and relativistic attacks designed to show it has no useful content. The medical profession has been attacked recently on the ground that the 'patient-health' norm conflicts with more fundamental general moral principles, especially that of personal autonomy. This criticism is justified with respect to the interpretation of the patient-health norm which has often been given by the medical profession. A more careful investigation of both the empirical requirements of successful treatment and the concept of health itself shows that the theoretical conflict is largely resolvable. This implies that the traditional basic medical norm is morally appropriate.

Codes of Ethics↗

PubMed2006

Trends in acceptance of euthanasia among the general public in 12 European countries (1981-1999).

BACKGROUND: We wanted to examine how the acceptance of euthanasia among the general public in Western Europe has changed in the last decades, and we wanted to look for possible explanations. METHODS: We analysed data from the European Values Surveys, held in 1981, 1990, and 1999-2000 in 12 West European countries. In each country, representative samples of the general public were interviewed using the same structured questionnaire in all countries. Euthanasia was explained in the questionnaires as 'terminating the life of the incurably sick'. RESULTS: A total of 46 199 respondents participated in the surveys. A significant increase in acceptance of euthanasia could be observed in all countries except (West) Germany. While the average increase in euthanasia acceptance was 22%, the increase was particularly obvious in Belgium, Italy, Spain, and Sweden. Although changes in several characteristics of respondents, such as decrease in religious beliefs, rising belief in the right to self-determination, and (to a lesser extent) rise in levels of education, were associated with growing acceptance of euthanasia, they could only partly explain the increase of euthanasia acceptance over the years. CONCLUSIONS: An increase of euthanasia acceptance among the general public took place over the last two decades in almost all West European countries, possibly indicating a growing support for personal autonomy regarding medical end-of-life decisions. If this trend continues, it is likely to increase the public and political debate about the (legal) regulation of euthanasia under certain conditions of careful medical practice in several West European countries.

Adolescent↗

PubMed1996

Are the similarities between a woman's right to choose an abortion and the alleged right to assisted suicide really compelling?

In this Article, Marc Spindelman examines the relationship between abortion and assisted suicide. He begins his discussion with the constitutional framework within which courts should consider the assertion that the Due Process Clause of the Fourteenth Amendment protects the individual's decision to commit assisted suicide. The Author then considers and, based on relevant Supreme Court doctrine, rejects the conception of personal autonomy that undergirds the claimed constitutional right to assisted suicide. Finally, the Author points out some legal and cultural distinctions between abortion and assisted suicide, arguing that these distinctions offer courts good reasons for holding that the Fourteenth Amendment's promise of liberty does not include the liberty to commit assisted suicide. In addition, the Author makes a few observations about recent assisted-suicide cases decided by the Ninth and Second Circuits.

Abortion, Legal↗

PubMed2004

Posthumous sperm retrieval for the purpose of later insemination or IVF in Israel: an ethical and psychosocial critique.

In October 2003, the Attorney General of the Government of Israel published guidelines allowing posthumous sperm retrieval for the purpose of later insemination or IVF by the surviving female partner. This paper presents an ethical and psycho-social critique of the guidelines, which challenges their basic premise that personal autonomy over-rides any other ethical principle and argues that the autonomy of the adult should not over-ride the well-being of the offspring. It also shows that, despite the centrality of autonomy in the guidelines, they actually infringe on the autonomy of the deceased, and pose challenges to that of the surviving partner. It questions the propriety and very possibility of ascertaining the 'presumed wishes' of the deceased for a posthumous child. Finally, it argues against the document's presentation of posthumous sperm retrieval as a medical procedure and contends that, on the contrary, medicine and science are suborned to the exploitation of the dead.

Cadaver↗

PubMed2006

Health care decision-making capacity: a legal perspective for long-term care providers.

While federal law establishes guidelines that designated facilities must follow in providing information about a patient's rights regarding self-determination in the health care decision-making process, state law determines the decision-making process and the legal requirements pertaining thereto. A person's capacity to make health care decisions or to have the authority and capacity to delegate the right to make such decisions is a legal conclusion based on statutory and common law principles. This article discusses the legal perspective of capacity in health care decision making and the legal framework of the question of whether or not a person has the capacity to make health care decisions. Western civilization's concepts of personal autonomy and self-determination are at the core of health care decision making, but health care providers must be aware that other cultures do not always share that value system. Sensitivity to multicultural diversity in this context is imperative to maintain individual self-esteem and respect, both for the patient and the patient's family.

Advance Directives↗

PubMed2001

Cultural assessment in bioethical advocacy--toward cultural competency in bioethical practice.

The continued diversification of the U.S. population poses increasing challenges for bioethical advocates (e.g., ethicists, physicians, nurses, social workers, psychologists, surrogates, researchers, and lawyers), especially those serving rapidly expanding and culturally varied populations. The issue from the bioethics perspective is that the members of ethnically diverse groups often bring different normative expectations and their own preferred decision-making formats to the bioethics table. For example, some advocates will encounter a "collectivity," or the family-as-a-whole rather than the individual, as a decision maker. In other instances, they may encounter cultural groups whose members (or some of whose members) will value the principle of beneficence more than personal autonomy. Moreover, such value-based challenges are likely to continue since forecasters predict that diversification will actually quicken in the United States throughout the next five decades. In the face of these changes in the bioethical climate, advocates must be prepared to strengthen their cultural assessment skills. Taking a multidimensional approach to the problem yields a four-point cultural assessment model to help advocates handle the great diversity of outlook and orientation among their culturally diverse clientele.

Beneficence↗