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PubMed2006

Separation-survivability--the elusive moral cut-off point?

Act 92 of 1996, the Choice on Termination of Pregnancy Act, seeks to promote female autonomy. The Act makes no reference to the nature of the abortus--implying its moral insignificance. Utilitarian arguments on the value of life strongly support this position. Utilitarians argue that neither belonging to the human species, nor possession of the potential to develop into a person, is a significant intrinsic characteristic in determining the value of life. For them the entrance requirement to any conception of moral significance is sentience--the ability to suffer. Full moral significance is only accorded to 'persons'. A person is someone who has attained a sufficient level of self-awareness to have an interest in the continuance of its existence. This develops some time after birth. 'Conservatives' argue for conception as the moral cut-off point after which termination is morally unacceptable; 'liberals' hold that there is no such prenatal point. Both of these notions are problematic, as is the notion of sentience. We argue that separation-survivability is the only morally acceptable cut-off point, based on four premises, viz. (i) a particular notion of potentiality; (ii) the inextricable, mutual relationship between human beings and their world (without either, the other cannot exist); (iii) the moral correspondence of the viable fetus and the neonate; and (iv) the moral unacceptability of infanticide. We support a graded position on the value of prenatal human life, and a 'moderate' stance on termination--that notwithstanding possessing some moral significance, other arguments may trump this up to the point of separation-survivability. This seriously problematises 'partial birth' abortion, and the utilitarian argument on the value of life.

Abortion, Legal↗
PubMed1996

Cost savings at the end of life. What do the data show?

Medical care at the end of life consumes 10% to 12% of the total health care budget and 27% of the Medicare budget. Many people claim that increased use of hospice and advance directives and lower use of high-technology interventions for terminally ill patients will produce significant cost savings. However, the studies on cost savings from hospice and advance directives are not definitive. The 3 randomized trials show no savings from these interventions, but either they are too small for confidence in their negative results or their intervention and cost accounting are flawed. The nonrandomized trials of hospice and advance directives show a wide range of savings, from 68% to none. Five methodological issues obscure the assessment of these studies: (1) selection bias in those patients who use hospice and advance directives, (2) the different time frames of assessing the costs, (3) the limited types of medical costs evaluated, (4) the variability of reporting the savings, and (5) the lack of generalizability of the findings to other patient populations. A more definitive study that assessed patients' end-of-life care preferences, use of hospice and advance directives, and direct and indirect costs would be desirable. In the absence of such a study, the existing data suggest that hospice and advance directives can save between 25% and 40% of health care costs during the last month of life, with savings decreasing to 10% to 17% over the last 6 months of life and decreasing further to 0% to 10% over the last 12 months of life. These savings are less than most people anticipate. Nevertheless, they do indicate that hospice and advance directives should be encouraged because they certainly do not cost more and they provide a means for patients to exercise their autonomy over end-of-life decisions.

Advance Directives↗
PubMed1996

Exercising restraint: autonomy, welfare and elderly patients.

Despite moves to enhance the autonomy of clients of health care services, the use of a variety of physical restraints on the freedom of movement of frail, elderly patients continues in nursing homes. This paper confronts the use of restraints on two grounds. First, it challenges the assumption that use of restraints is necessary to protect the welfare of frail, elderly patients by drawing on a range of data indicating the limited efficacy of restraints. Secondly, it argues that the duty to respect individual autonomy extends to a duty to respect the autonomy of patients who are elderly, frail and living in nursing homes.

Aged↗
PubMed2001

Patient autonomy and medical paternity: can nurses help doctors to listen to patients?

Nurses are increasingly faced with situations in practice regarding the prolongation of life and withdrawal of treatment. They play a central role in the care of dying people, yet they may find themselves disempowered by medical paternalism or ill-equipped in the decision-making process in end-of-life situations. This article is concerned with the ethical relationships between patient autonomy and medical paternalism in end-of-life care for an advanced cancer patient. The nurse's role as the patient's advocate is explored, as are the differences between nursing and medicine when confronted with the notion of patient autonomy. The impetus for this discussion stems from a clinical encounter described in the following scenario.

Female↗
PubMed1998

Respect for autonomy: issues in neurological rehabilitation.

OBJECTIVE: To examine the ethical principle of respect for autonomy within the context of neurological rehabilitation. DISCUSSION: The nature of the principle of respect for autonomy is examined, and specific difficulties to which it may give rise in this area of practice are identified. These concern difficulties of communication with neurologically impaired patients, issues of competence related to patient decision-making, problems of consensus between patient and professional, and the role of the patient's family in the rehabilitation process. CONCLUSION: A number of strategies, based on a client-centred model of practice, are suggested which may counteract these difficulties and assist in respecting the patient's autonomy to the appropriate degree, while seeking to attain high-quality clinical outcomes.

Beneficence↗
PubMed2006

Patients' dignity in a rehabilitation ward: ethical challenges for nursing staff.

The purpose of this study was to explore the challenges met by nursing staff in a rehabilitation ward. The overall design was qualitative: data were derived from focus interviews with groups of nurses and analyzed from a phenomenological-hermeneutic perspective. The main finding was that challenges emerge on two levels of ethics and rationality: an economic/administrative level and a level of care. An increase in work-load and the changing potential for patient rehabilitation influence the care that nurses can provide in rehabilitating patients, and therefore also affect patients' feelings of self-worth and dignity. Some patients wish to maintain their independence and autonomy, whereas others seem to 'lose themselves'. Independence and autonomy are associated with dignity, but their lack is contrary to it.

Activities of Daily Living↗
PubMed1992

Ethical and psychosocial considerations of wound management.

Ethical and psychosocial considerations in caring for patients with pressure ulcers are explored in relation to the consequential and the nonconsequential schools of ethical thought. The principles of ethical decision making are related to wound management in terms of beneficence, nonmaleficence, justice, veracity and confidentiality, autonomy and liberty. Allocation of scarce resources and the conduct of research influence ethical decision making in wound management.

Beneficence↗
PubMed2005

Do higher status and more autonomous women have longer birth intervals? Results from Cebu, Philippines.

We look at whether women's status and autonomy affect birth-to-conception intervals using data from the Cebu Longitudinal Health and Nutrition Survey (CLHNS) in the Philippines. We followed 1123 married, fecund women, aged 25-49, for up to 5 years. In a 1994-1995 survey, women were asked about the timing of their last birth. In 1998-2000, women were asked about any pregnancies since the 1994-1995 survey. Using these two surveys, we calculated birth to conception intervals. Women were censored if they reached their 50th birthday during follow-up. We measure autonomy based on whether the wife has the final say in 10 household decisions as measured in the 1994-1995 survey. Using Cox proportional hazards models we find that women with more decision-making autonomy have significantly longer birth-to-conception intervals in unadjusted models. After adjustment for age, wealth, education, other socio-economic variables, and women's status, decision-making autonomy remained a significant predictor in all models. This effect remains even after adjusting for contraceptive use, implying that autonomy influences birth-to-conception intervals through other mechanisms above and beyond increased contraceptive use. Additionally, few of the women's status variables were significantly associated with time to next conception. Women who had their first birth later in life were more likely to conceive during the observation period suggesting that they may be having shorter birth intervals in order to "catch up" with their peers. Maternal and child health-care efforts can help women achieve their desired spacing goals by supporting women's autonomy-in addition to ensuring they have accurate information and a range of contraceptive options.

Adult↗