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Current bioethics scholarship and pedagogy suffers from an insufficient correlation with the realities and variables of clinical medicine, particularly in its dominant paradigm of patient autonomy. Reference to various basic clinical factors will be made here toward proposing certain conceptual, tactical and pedagogical modifications to this paradigm.
The ends and means of public health activities are suggested to be at odds with the values held by human individuals and communities. Although promoting longer lives in better health for all seems like an endeavour that is obviously acceptable, it can be challenged by equally self-evident appeals to autonomy, happiness, integrity and liberty, among other values. The result is that people's actual concerns are not always adequately dealt with by public health measures and assurances.
In its American context the case of baby Messenger, a preterm infant disconnected from life-support by his father and allowed to die has generated debate about neonatal treatment protocols. Limited by the legal and ethical norms of the United States, this case did not consider treatment protocols that might be available in other countries such as Denmark and Israel: threshold protocols whereby certain classes of newborns are not treated, and preemptive abortion allowing one to choose late-term abortion rather than risk delivery. Each offers a viable and ethically sound avenue for dealing with the economic and social expense of anomalous newborns by aborting or not treating those most likely to burden the health care system. Objections that these protocols are antithetical to American bioethical principles are considered but rejected as each policy answers to economic justice, utility and respect for autonomy.
Patients in nursing homes sometimes give accounts of episodes in which they feel their autonomy and/or self-respect are violated as a result of the care they receive from nursing staff. In these ethically difficult care situations nurses use strategies such as negotiation, explanation and, in some cases, restraint. This study investigates how nurses apply these strategies to resolve ethical dilemmas in such a way that patients experience respect rather than violation. Critical issues that will be discussed include the definition of ethically difficult care situations in nursing homes and the identification of strategies for resolving such situations. Examples of the use of three strategies are presented. The use of negotiation, restraint and explanation are discussed in order to ensure respect for patients' autonomy and thus to optimize health care outcomes.
The purpose of this study was to develop a survey tool for assessing the satisfaction of elderly long-term care (LTC) residents with the meals and food services they receive, as well as to assess quality of life issues related to eating. Food service delivery should be provided in an environment that fosters autonomy, interpersonal relations, and security. The questionnaire was administered as face-to-face interviews with 205 residents (> or = 65 years of age) of 13 LTC facilities in Saskatoon, Saskatchewan, Canada (participation rate = 67%). Residents expressed some concern with food variety, quality, taste, and appearance, and with the posting of menus. Quality of life issues were mostly positive; however, residents were less satisfied with areas related to their autonomy such as food choice and snack availability.
Ethical dilemmas in family practice have increased in frequency and complexity as both the potential benefit and the potential harm of medical treatments have increased. All physicians must be aware of moral issues relating to medicine. Family physicians commonly face ethical problems concerning the patient with diminished autonomy; the right to refuse treatment; allocation of resources; informed consent; surrogate consent (for children, for the incompetent, and for those with diminished autonomy); and the appropriate level of aggressiveness in treatment.
Patient competence is a prerequisite to fulfilling the primary ethical principle of patient autonomy or self-determination. This article defines the legal designation of incompetence and describes the components of the assessment of a patient's decision-making capacity. These assessments occur within the context of relationships, the most influential of which is that between the nurse and patient. Attention to the nurse-patient relationship promotes patient autonomy, patient advocacy, and decision making based upon the patient's values--which is, ultimately, ethical health care.
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We determined the prevalence of written cardiopulmonary resuscitation policies in North Carolina nursing homes and evaluated their content according to predetermined criteria. Questionnaires were mailed to 236 state-registered facilities. Two hundred nine nursing homes (88.5%) responded to the questionnaire; 83% reported having a written policy, and half (86 nursing homes) provided copies. Nine of ten nursing homes reported that cardiopulmonary resuscitation was performed at their institution, and a similar number (92%) permitted physician orders restricting cardiopulmonary resuscitation. Written policies were systematically compared with 10 model criteria. Policy content varied substantially. More than half of the policies contained provisions for authorization, informed consent, documentation, competency, review, and applicability of do not resuscitate orders. Less than half contained criteria for autonomy, treatment alternatives, dignity and quality of care, and patient identification. Nursing homes that had written policies were newer, larger, and for-profit; had a greater proportion of skilled nursing care beds; and were more likely to have both Medicare and Medicaid certification. The variations in these policies place nursing home residents at risk for having important personal rights limited or ignored. Inclusion of these 10 policy criteria in a comprehensive cardiopulmonary resuscitation policy would represent an important step toward enhancing the quality of decision making by nursing home residents.
OBJECTIVE: This study investigated the palliative options available when a patient requested euthanasia or physician-assisted suicide (EAS), the extent to which the options were applied, and changes in the patient's wishes. METHODS: In an observational study, 3614 general practitioners (GPs) filled in a questionnaire and described their most recent request for EAS (if any) (n = 1,681). RESULTS: Palliative options were still available in 25% of cases. In these cases options were applied in 63%; in 46% of these cases patients withdrew their request. Medication other than antibiotics, which was most frequently mentioned as a palliative option (67%), and applied most frequently (79%), together with radiotherapy, most frequently resulted in patients withdrawing their request. SIGNIFICANCE OF RESULTS: GPs include the availability of palliative options in their decision making when considering EAS. The fact that not all options are applied or, if applied, the patient persists in the request is related to autonomy of the patient, the burden on the patient, and medical futility of the option.
Anyone interested in the morality of suicide reads David Hume's essay on the subject even today. There are numerous reasons for this, but the central one is that it sets up the starting point for contemporary debate about the morality of suicide, namely, the debate about whether some condition of life could present one with a morally acceptable reason for autonomously deciding to end one's life. We shall only be able to have this debate if we think that at least some acts of suicide can be moral, and we shall only be able to think this if we give up the blanket condemnation of suicide that theology has put in place. I look at this strategy of argument in the context of the wider eighteenth-century attempt to develop a non-theologically based ethic. The result in Hume's case is a very modern tract on suicide, with voluntariness and autonomy to the fore and with reflection on the condition of one's life and one's desire to carry on living a life in that condition the motivating circumstance.
In this study, we examined the relations between biological maturity status, body mass index, age, and perceptions of adult autonomy support in the context of youth soccer. A total of 70 female and 43 male soccer players, aged 9 - 15 years, completed three adult-specific versions (i.e. mother, father, coach) of the perceived autonomy support subscale from the Interpersonal Style Scale. The participants' percent predicted adult stature was used as an estimate of biological maturity status. Multiple linear regression analyses revealed that advanced maturity status in male players predicted lower perceptions of autonomy support from the coach. Maturity status was unrelated to perceptions of autonomy support from the coach in female soccer players, and paternal and maternal autonomy support in male and female players. Age and body mass index were unrelated to perceptions of adult (i.e. coach, mother, father) autonomy support in male and female players.
The present experimental research examined whether framing early adolescents' (11- to 12-year-olds) learning activity in terms of the attainment of an extrinsic (i.e., physical attractiveness) versus intrinsic (i.e., health) goal and communicating these different goal contents in an internally controlling versus autonomy-supportive way affect performance. Both conceptual and rote learning were assessed. Three experimental field studies, 2 among obese and 1 among nonobese participants, confirmed the hypothesis that extrinsic goal framing and internal control undermine conceptual (but not rote) learning, even in comparison with a control group. Study 3 indicated that the positive effect of intrinsic goal framing on conceptual learning was mediated by task involvement, whereas the positive effect of autonomy-supportive communication style on conceptual learning was mediated by relative autonomous motivation.
A case involving a patient sitting for an initial licensure examination is used to develop several ethical issues in detail. These include misalignment of those bearing the risks and dangers of such tests, lack of respect for patient autonomy, and compromises in the standard of care and avoidable and dysfunctional stress inherent in the examination system as it is currently conducted.
Agreeing in large part with Cameron, Robert D. Orr nonetheless raises some questions. He points out the theological origins of bioethics in the 1960s, while admitting that the field has since become secularized. Autonomy's challenge to Hippocratic paternalism has brought real benefits but also abuses. Bioethics addresses more than procedural matters; it deals in issues of real substance.
PURPOSE: This study was conducted to characterize (1) the autonomy of service users, both frail elderly and of their family caregivers, in selecting Long-term care insurance services, and to evaluate (2) influencing demographic factors. The aim was to propose new directions for the care providing system. METHODS: The subjects were 1,760 users of public Long-term Care Insurance who were randomly stratified and sampled in Higashi-osaka city, Osaka prefecture. Data were collected through a mailed anonymous self-report questionnaire in October, 2001. The number returned was 1,178 (66.9%). In this study, 723 eligible cases were analyzed in separate models: 146 cases for the elderly model, and 577 for the family model. Multiple regression analysis and two-way analysis of variance were performed to identify factors which have direct and interactive effects, respectively, on the autonomy. RESULTS: 1) The degree of autonomy of the elderly (3.1 +/- 0.8 (range 1-4)) was high in comparison with the family (2.8 +/- 0.8). 2) In the elderly model, the ability to collect service information and the level of knowledge about the service contents had a direct effect on the autonomy. In the family model, ability to collect service information and the level of knowledge about the service contents, the degree of informing the provider of own care needs, and good relations among family members had direct effects. 3) In the elderly model significant two-way interactive effects on the autonomy were observed between the level of knowledge about the service contents and the age; attitudes of the service providers and the age or gender of the recipient; the degree of informing the provider of own care needs and the gender. In the family model, significant interactions were noted between the attitudes of the service providers and the age of the family caregiver; the level of congitive disorders of the elderly and the length of service usage. CONCLUSIONS: It was clarified that the score for autonomy of the family was low in comparison with that for elderly, and the essential requisites of service providers for enhancing the autonomy of elderly people and families may vary depending on the basic characteristics or the situation of the user. It was suggested that support to enhance users autonomy should be provided by taking the demographic factors of the user into consideration.
Divergent perspectives of the nature of substance use have shaped societal attitudes and legislative action toward management of the implications of drug abuse and addiction at an individual and societal level. When it comes to substance abuse issues, policy and ethical analysis become intertwined. The current review entails an ethical evaluation of drug addiction, involving a comparison of different perspectives of substance use and an assessment of the treatment approaches and legal policies derived from these models. The aims of substance use policy directives will be ethically considered in terms of the balance of harm versus benefit, patient/client autonomy and rights and the duties or role of the health care provider in dealing with the problems of addiction.