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Death of John Paul II and the basic human care for the sick and the dying.

The death of Terri Schiavo by starvation and its sanction by some United States Courts indicates the alarming revival of the eugenics and euthanasia movement. From the legal sanction of physician-assisted suicide, the euthanasia movement now tries to advance the legal protection for "mercy killing." Terri was diagnosed with persistent vegetative state, a term that is outdated, vague and imprecise and that likens a human being to a vegetable. Medical literature indicates that patient with so-called "persistent vegetative state" can recover, and that they do experience pain. The euthanasia movement, linked to eugenics in its origin and present day influence in bioethics espouses the Nazi notion of "lives not worth living," unlimited patient autonomy, and philosophical utilitarianism. John Paul II countered the eugenic philosophy with the classical Western concept of man as the image and likeness of God, responsible for the care of himself and society as a whole. He taught in writing and by example that food and water are basic human care that every person should receive. In the last days of his life he showed a judicious use of proportionate or ordinary means to maintain life. He chose to forego disproportionate medical treatment when there was no reasonable hope of recovery. At that point he continued to receive ordinary medical care, together with basic human and spiritual care.

Catholicism↗

Perceived autonomy and relatedness as moderating the impact of teacher-student mentoring relationships on student academic adjustment.

This study examined the impact of a 10-hour teacher-student mentoring relationship on the academic adjustment of at-risk college students. A quasi-experimental design involving a comparison group (NM: students with No Mentor), a High Relatedness/Autonomy group (HR/HA: students who perceived high levels of relatedness and autonomy during the mentoring process) and a Low Relatedness/Autonomy group (LR/LA: students who perceived low levels of relatedness and autonomy during the mentoring process) was used for that purpose. Academic adjustment and performance were assessed before (Time 1) and five months after involvement in mentoring (Time 3) for all students. Perceived relatedness and autonomy were assessed after the last mentoring meeting (Time 2) for students involved in mentoring relationships only. Results indicated better social adjustment and institutional attachment in college for the HR students than for the LR and NM students, even after controlling for initial adjustment, performance and social network dispositions. In addition, the LR and LA students presented lower academic and emotional adjustment in college and lower academic performance than NM, HR, and HA students. The potential positive and negative impacts of mentoring relationships are discussed in light of autonomy and relatedness processes. Editors' Strategic Implications: Especially valuable is the articulation of why mentoring might be expected to affect social and academic adjustment outcomes via its effects on the development of autonomy and relatedness. Application of attachment theory and measurement to the study of mentoring is a strategy that shows promise.

Achievement↗

Awareness in dementia: ethical and legal issues in relation to people with dementia.

Our improved understanding of the experience of people with dementia provides a new impetus to address legal and ethical issues. This paper explores emerging issues in relation to awareness in dementia and its impact on legal and ethical matters. The different approaches and principles demonstrated in relation to ethical issues are discussed, with an exploration of the concepts of beneficence, non-maleficence, autonomy, and paternalism. Application of these concepts is discussed in relation to advance directives, capacity, and decision making, participation in research and treatment, including informed consent, and truth telling. The tensions that exist between the imperatives of doing no harm and of maintaining autonomy in addressing legal and ethical issues are highlighted, and attention drawn to the manner in which the attribution of unawareness is used to justify withholding autonomy. The review emphasizes the importance of considering competency and awareness as being multi-faceted, to be understood in the context of social interaction.

Cognition↗

Patient truthfulness: a test of models of the physician-patient relationship.

Little attention has been given in medical ethics literature to issues relating to the truthfulness of patients. Beginning with an actual medical case, this paper first explores truth-telling by doctors and patients as related to two prominent models of the physician-patient relationship. Utilizing this discussion and the literature on the truthfulness and accuracy of the information patients convey to doctors, these models are then critically assessed. It is argued that the patient agency (patient autonomy or contractual) model is inherently and seriously flawed in numerous circumstances, even those involving informed and competent adult patients.

Adult↗

Discrepancies between mother and adolescent perceptions of diabetes-related decision-making autonomy and their relationship to diabetes-related conflict and adherence to treatment.

OBJECTIVE: To document the relationship between discrepancies in mother and adolescent perceptions of diabetes-related decision-making autonomy, diabetes-related conflict, and regimen adherence. METHODS: The sample was composed of 82 mother-adolescent dyads. Measures included adolescent and mother reports of diabetes-related decision-making autonomy, diabetes-related conflict, and regimen adherence. Nurses' reports of adherence and number of glucose tests performed each day were also obtained. RESULTS: Discrepancies between mother and adolescent perceptions of decision-making autonomy were related to greater maternal report of diabetes-related conflict. In particular, when adolescents reported that they were more in charge of decisions than reported by their mothers, mothers reported more conflict. Discrepancies between mother and adolescent perceptions of decision-making autonomy were not related to regimen adherence. CONCLUSIONS: The findings suggest that discrepancies between mother and adolescent perceptions of diabetes-related decision-making autonomy may be a potentially important area for intervention.

Adolescent↗

Competency after a suicide attempt: an ethical reflection.

The provision of critical care services can be complicated by ethical problems involving competency. When a patient's competency is in doubt there is conflict between the principles of autonomy and paternalism. The authors describe an ethical situation involving attempted suicide and administration of chemical restraints where the patient's competency was in doubt.

Adult↗

Physician assessment of patient competence.

OBJECTIVE: To determine if physicians know and can apply the legal standard for determining competence; to determine if physician assessment of competence varies by physician age or specialty. DESIGN: Mail survey with specific questions about a patient scenario and general questions about the law. PARTICIPANTS: 2100 randomly selected Massachusetts internists, surgeons, and psychiatrists. MEASUREMENTS: In Part I, the survey presented a scenario adapted from a court case that involved an elderly woman's refusing lifesaving surgery. The scenario was divided into three sections: the medical history, the patient's rationale, and a psychiatrist's opinion that the patient was incompetent. Respondents were not told that an appellate court later decided the psychiatrist applied the wrong standard of competence and the patient was indeed competent. Respondents were asked whether the patient was competent, whom they would consult, and how they would respond. Part II posed a series of theoretical questions about competence. Group differences were tested by chi-square. MAIN RESULTS: Surveys were returned by 823 (41%) of the sample. In Part I, before the psychiatrist's opinion, 58% thought the patient was competent, 92% would consult a psychiatrist to help assess competence, and only 17% would to go to court. After the psychiatrist's opinion, only 30% thought she was competent and 55% would go to court. In Part II, 89% knew the correct standard for competence; however, most incorrectly responded that conditions such as dementia and psychosis establish incompetence. Psychiatrists performed significantly better on theoretical, but frequently worse on scenario, questions. CONCLUSIONS: Physicians in general, and psychiatrists in particular, know the standard for competence but may apply it incorrectly. This suggests that the common clinical practice of relying on expert medical opinion may introduce bias and produce inaccurate results that undermine patient autonomy.

Age Factors↗

Asthma in middle schools: what students have to say about their asthma.

Preadolescence involves cognitive, social, and physiological changes along with changes in the child's environment. During this developmental stage, young adolescents are transitioning into middle school, forming a larger social network, and managing parental expectations for assuming more responsibility for self-care. The impact of these developmental changes on asthma management is not well understood. The purpose of this study was to better understand asthma and asthma management from the perspective of middle school students. A partnership was formed between the university researcher, several school nurses, and a representative of the health department, through the Orange County Asthma Coalition. Funds were secured from the American Lung Association. School nurses helped to identify and recruit 50 middle school students with asthma to participate in focus groups. The focus-group discussions centered on asthma management with implications for intervention development. Analyses sought to identify developmental issues that affect management. Results indicated that the transition to middle school represents a challenge to managing asthma. As compared with the elementary school environment, support structures are broader and more diffuse, physical education is more demanding, and peer pressure is greater. Nevertheless, the desire for greater autonomy and independence in self-care was strong, particularly among eighth graders. Most interventions are designed for either children or adults, without recognizing the important developmental changes that are occurring in preadolescents with implications for asthma management. A school-based intervention in middle school may help students with asthma transition to greater autonomy of care, while easing transition in other domains of life.

Adolescent↗

Ethical dilemmas in community mental health care.

Ethical dilemmas in community mental health care is the focus of this article. The dilemmas are derived from a discussion of the results of a qualitative research project that took place in five countries of the European Union. The different stakeholders are confronted with the following dilemmas: community care versus hospital care (clients); a life with care versus a life without care (informal carers); stimulation of the client toward greater responsibility versus protection against such responsibility (professionals); budgetary control versus financial incentives (policy makers), and respect for the client versus particular private needs (neighbourhood residents). These dilemmas are interpreted against the background of a value based ethical model. This model offers an integral approach to the dilemmas and can be used to determine policy. The dilemmas are discussed here as the result of conflicting values-namely autonomy and privacy, support and safety, justice and participation, and trust and solidarity.

Activities of Daily Living↗

Women's autonomy and child survival: a comparison of Muslims and non-Muslims in four Asian countries.

In this article, I evaluate the hypothesis that higher infant and child mortality among Muslim populations is related to the lower autonomy of Muslim women using data from 15 pairs of Muslim and non-Muslim communities in India, Malaysia, the Philippines, and Thailand. Women's autonomy in various spheres is not consistently lower in Muslim than in non-Muslim settings. Both across and within communities, the association between women's autonomy and mortality is weak, and measures of autonomy or socioeconomic status are generally of limited import for understanding the Muslim disadvantage in children's survival.

Adult↗

Alzheimer disease and the "then" self.

The authority of the intact self over the future severely demented self is based on notions of integrity and precedent autonomy. Despite criticism of this authority, the principle of precedent autonomy in the care of people with Alzheimer disease or other progressive and irreversible dementias retains its moral significance.

Advance Directive Adherence↗

Dilemmas in mandatory reporting of domestic violence: carative ethics in emergency rooms.

Laws are clear when it comes to reporting child abuse, elder abuse, or maltreatment of the disabeled; however, the fuzzy area of domestic violence, or injury to women by their husbands or intimates, puzzles the system ethically and legally. Experts are divided on the issue of mandatory reporting of domestic violence by health care professionals. As exemplified by the Florida law, the crux of the problem may be twofold. First, the law requires reporting of certain incidents that are ambiguously defined. Second, reporting may be mandatory without the patient's consent. Many experts in the field of domestic violence suggest that mandated reporting by health care workers is not in the best interests of the victims; it may lead to more violence and increase the victim's reluctance to get needed health care. This victim vulnerability creates ethical dilemmas in the emergency department, often the first outside contact after a violent incident. This paper examines the implications of reporting applied to emergency practice in the context of basic ethical standards. The application of mandatory reporting laws to competent adult victims presents questions related to nonmaleficence, beneficence, autonomy, confidentiality, and a variety of contextual issues that arise from these main ethical domains.

Adult↗

[Parents' experiences with life-and-death decisions concerning their premature infants].

BACKGROUND: The study is concerned with parents' experience with life-and-death decisions concerning their premature infants in hospitals neonatal units. What are parents' attitudes towards their being involved in such decision-making? MATERIAL AND METHODS: During the 1997-2000 period, 20 qualitative interviews with 35 parents of 26 children were made. A qualitative, comparative method (grounded theory) was used for the analysis, which was carried out in parallel with data collection. RESULTS: Parents are exposed to great mental pressure, which may bring about a sense of ambivalence and a wish to avoid responsibility. Most parents do not wish to have the final word in decisions concerning their infant's life or death. Such a responsibility is likely to make parents feel guilty and puts too heavy a burden on the parents, but parents wish to be informed and taken seriously in the decision making-process. INTERPRETATION: Parents value health professionals' communication and information more than parent autonomy and right to choose.

Attitude to Death↗

Determinant role of education in the ethical aspects of resuscitation: a German/Hungarian comparison.

UNLABELLED: Introduction, objectives: Bioethical principles concerning Do Not Attempt Resuscitation (DNAR) orders are connected significantly with education according to our previous investigation. In order to confirm the hypothesis, Hungarian results were compared with the data gained from a highly qualified homogeneous group of German doctors, showing similar cultural traditions. METHODS: The questionnaire investigated the factors influencing DNAR orders as functions of intensive medical experience, ideological view and professional education, using a 5-point visual analogue scale. Answers were assigned to categories of autonomy, futility, obtainable quality of life, resource utilization and a category of other factors detailed later. RESULTS: The DNAR decision and termination of resuscitation are to almost the same extent determined by futility (3.29+-0.75; 3.49+-0.71) and obtainable quality of life (3.13+-1.31; 3.47+-1.34). The opinion of head of department was also important (3.24+-1.35; 3.23+-1.36). Patient's autonomy played an important role (3.15+-0.85; 2.36+-1.48) in decision making. In comparison with the Hungarian results, the only significant difference was found in the field of patient's autonomy in both not starting (p<0.0002) and terminating resuscitation (p<0.02) in favour of German doctors respecting it. DISCUSSION: The results support the original hypothesis that consideration of modern bioethical principles, and especially the patient's autonomy are related to the level of the doctor's education. Comparing to Hungarian data there is only a minimal difference in other bioethical points, while the population of German doctors interviewed appreciated the patient's autonomy significantly higher. There should be greater discussion of ethical considerations in cardiopulmonary resuscitation education.

Attitude of Health Personnel↗

The DNR decision--Part II. Ethical principles and application.

The medical literature presents conflicting messages and nonspecific guidelines regarding the DNR decision. Ethical principles address the questions: who should decide and for whom? Most sources acknowledge the competent patient's right to refuse treatment, but there is less agreement about resuscitating patients unlikely to recover from the underlying illness. The principles of nonmaleficence and paternalism come into play when the physician's professional duties to prevent suffering and to provide "death with dignity" begins to conflict with the patient's autonomy. Competent adults have the right to participate in decisions regarding their care. Whether this right includes the right to demand as well as refuse certain treatments is not clear. For physicians who institute DNR status without the patient's or family's consent, paternalism and professionalism have overridden patient autonomy. In that case, nonmaleficence is the basis of the physician's view of CPR as a harmful burden.(ABSTRACT TRUNCATED AT 250 WORDS)

Beneficence↗

Relations between parenting and externalizing and internalizing problem behaviour in early adolescence: child behaviour as moderator and predictor.

In this longitudinal study we investigated relations between parenting and externalizing and internalizing problem behaviour during early adolescence. First, we examined parenting effects on problem behaviour, including child behaviour as a moderator. Second, we examined child behaviour as predictor of parenting, also including moderator effects. A total of 650 13- to 14-year-olds filled out the Youth Self-Report and questionnaires about parenting at two times within a one-year interval. Relations between parenting and problem behaviour appeared to be stronger for externalizing than for internalizing problem behaviour. Both parenting effects and child effects were found. Parenting significantly predicted an increase in externalizing problem behaviour one year later. Adolescent's previous level of problem behaviour predicted changes in parenting (involvement and decisional autonomy granting). In addition, parental and child characteristics interacted in predicting outcome.

Adolescent↗