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PubMed2004

Consumption and its discontents: addiction, identity and the problems of freedom.

The focus of this paper is on the notion of 'addictive consumption', conceived as a set of discourses that are embedded within wider socio-historical processes of governance and control. It examines the discursive convergences and conflicts between practices of consumption and notions of addiction, which it notes are consistently represented in terms of the oppositional categories of self-control vs. compulsion and freedom vs. determinism. These interrelations are explored with reference to the development of notions of addiction, and their relation to shifting configurations of identity, subjectivity and governance. Finally, it suggests that the notion of 'addiction' has particular valence in advanced liberal societies, where an unprecedented emphasis on the values of freedom, autonomy and choice not only encourage the conditions for its proliferation into ever wider areas of social life, but also reveal deep tensions within the ideology of consumerism itself.

Behavior, Addictive↗
PubMed1983

Suicide in the elderly: the limits of paternalism.

It is the authors' premise that caregivers of the suicidal elderly patient are at times guided by a paternalism that is not always in the best interests of the patient. They advocate instead care based on greater respect for the autonomy of the patient. A case of a suicidal, recently widowed man is presented, and historical and ethical considerations of bereavement and suicide are discussed.

Aged↗
PubMed2006

Informed consent in neurosurgery--translating ethical theory into action.

OBJECTIVE: Although a main principle of medical ethics and law since the 1970s, standards of informed consent are regarded with great scepticism by many clinicans. METHODS: By reviewing the reactions to and adoption of this principle of medical ethics in neurosurgery, the characteristic conflicts that emerge between theory and everyday clinical experience are emphasised and a modified conception of informed consent is proposed. RESULTS: The adoption and debate of informed consent in neurosurgery took place in two steps. Firstly, respect for patient autonomy was included into the ethical codes of the professional organisations. Secondly, the legal demands of the principle were questioned by clinicians. Informed consent is mainly interpreted in terms of freedom from interference and absolute autonomy. It lacks a constructive notion of physician-patient interaction in its effort to promote the best interest of the patient, which, however, potentially emerges from a reconsideration of the principle of beneficence. CONCLUSION: To avoid insufficient legal interpretations, informed consent should be understood in terms of autonomy and beneficence. A continuous interaction between the patient and the given physician is considered as an essential prerequisite for the realisation of the standards of informed consent.

Attitude of Health Personnel↗
PubMed2000

Vaccination and other altruistic medical treatments: should autonomy or communitarianism prevail?

The publication of a report into a case where an organ donor's constraints on the race of potential recipients raises questions about whether respect for autonomy or communitiarianism should prevail in altruistic medical procedures. This article briefly reviews how autonomy and communitarianism are balanced in cadaveric and live organ donation, bone marrow donation, gamete donation, blood donation and vaccination. It criticizes vaccination policy for ostensibly respecting patient autonomy yet in practice compromising that autonomy in various ways. Vaccination is properly viewed as an altruistic medical procedure because some vaccines are of more good to society than to the vaccinee, who runs associated health risks. The conclusion is that there is a spectrum of attitudes to the value of autonomy, depending principally upon the invasiveness of the procedure. In most cases the autonomy-communitarianism balance is satisfactory, but this is not so in respect of cadaveric organ donation and vaccination. The article proposes that cadaveric organ donation should be governed by the communitarian law of well-publicised presumed consent. It proposes two alternatives for vaccination: that vaccination should be compulsory or, preferably, that procedures be modified so that parents have real autonomy in their decisions whether to vaccinate their children.

Adult↗
PubMed1996

Refusal of treatment, leading to death: towards optimization of informed consent.

Few medical decisions create more anguish than ones involving cessation of treatment, resulting in the death of a patient. In this article, the ethical and legal aspects of the withdrawal of treatment are examined with respect to a case of a 67-year-old man who fell and sustained a fracture of his second cervical vertebra, rendering him paralysed and respirator-dependent. He immediately requested the withdrawal of treatment, but his family baulked. Ethics consultation recommended delaying the decision, to give the patient enough time to foster optimal comprehension and synthesis of information related to his condition and the consequences; we refer to this process as "optimization of informed consent." When the patient was informed of the delay and the reasons for it, he was assured (and subsequently repeatedly reassured) of his ultimate right to refuse treatment at a future date. On balance, optimization of informed consent promotes patients' autonomy, even though it involves suspending this autonomy for a time. It is also consistent with physicians' responsibility to promote life and avoid premature death.

Aged↗
PubMed2003

Decision-making at the end-of-life and the incompetent patient: a comparative approach.

In contrast to the situation in the Netherlands and Belgium, the legislatures in both England & Wales and Germany have not recognised that active euthanasia may be lawful in any circumstance. Nevertheless, the courts in both jurisdictions have held that passive euthanasia, that is the withdrawal or withholding of life-prolonging treatment, is perfectly lawful; indeed it will often constitute good medical practice. This article adopts a comparative approach to assessing the manner in which decisions to withdraw or withhold life-prolonging treatment are made in relation to previously competent patients without a legally effective advance directive or a proxy decision-maker, considering the approaches adopted by the courts in England & Wales and Germany: the best interests and 'presumed will' approaches respectively. Due to the inherent drawbacks associated with each approach it is concluded that the best way forward would be for both jurisdictions to adopt a mixed approach, allowing the autonomy model to temper the best interests approach, recognising that the patient is an individual rather than simply an object of concern.

Decision Making↗
PubMed2006

'Reproductive autonomy' versus public good?

Hitherto sex selection could be achieved only by destroying any fetus or child of the unwanted sex. Sperm selection may change that. The technology could be used to 'balance' families. However its use in certain developing countries might 'unbalance' populations, with serious, if unintended, consequences.

Humans↗
PubMed1995

Incapacity and autonomy: striking a balance.

We want to take this opportunity to offer our perspective on some of the issues to which the Substitute Decisions Act, 1992, and the Consent to Treatment Act, 1992, represent a response. To a lesser extent, the provisions of the Advocacy Act, 1992, which governs the provision and role of advocates, will be considered. First, we hope to explain, perhaps a little more than can be done in Committee, or in the Legislature, the thinking that underlies some of the protective measures this legislation makes available to persons who are thought to be mentally incapable. Second, we provide some discussion of the problem of the criterion of mental capacity, and argue that where there is no strict criterion, it is important to ensure that individuals who are subjects of assessments of their mental capacity are protected by a balance of power in which they hold a prominent position. Third, we suggest that the lack of a strict criterion of capacity argues for a broad criterion for assessors.

Advance Directives↗
PubMed2002

Health risk escalators and the rehabilitation of offenders with learning disabilities.

This paper presents a study of risk management in a hospital within the UK. National Health Service which attempts to rehabilitate offenders with learning disabilities. Analysis is based on the metaphor of a 'risk escalator'. Health and social care systems can be characterised as risk escalators if they possess three attributes. Firstly, risk managers should agree the rough ordering of the severity of a set of related risks. Secondly, a repertoire of responses which provide different trade-offs between autonomy and safety, and which can be calibrated against risk severity, should be available. Thirdly, the potential for positive and/or negative feedback, which give risk escalators their dynamic character, should be identified. Risk escalators may be deliberately designed, or may, like the hospital regime discussed in this paper, coalesce from pre-existing sub-systems offering different autonomy/safety balances. They may carry service users upwards towards greater safety if needed, as in health screening systems, or downward towards greater autonomy if justified, for instance in rehabilitation systems. Their therapeutic status is contestable. Upward risk escalators can be accused of generating positive feedback, with iatrogenic effect. Downward risk escalators may be criticised for pushing service users too strongly towards less intense interventions, causing neglect. The present case study brings out emergent properties of a downward risk escalator, including: organisational disruption to system functioning; preferencing of safety over autonomy; active and reflexive system management by clients; multiple, organisational risk rationalities; and the reification of riskiness as a generic attribute of individuals.

Crime↗
PubMed1996

Common ethical dilemmas encountered in the management of HIV-infected women and newborns.

The clinical management of the HIV-infected pregnant woman and newborns involves multifaceted ethical challenges. We have argued that rights-based approaches, based on a civil rights model, are not adequate to clinically address these challenges. We have argued instead for a more nuanced ethical framework that emphasizes the beneficence-based obligations of the physician of the pregnant woman, to the fetal patient, and to the newborn, as well as the beneficence-based obligations of the pregnant woman to the fetal patient and to the newborn. The ethical principle of respect for autonomy shapes the counseling process about termination of pregnancy, contraception, and advance directives.

Adolescent↗
PubMed1995

Principle-based ethics and nurses' attitudes towards artificial feeding.

Nurses often institute artificial feeding for patients who would otherwise starve. Recently, the courts in the United States have favoured withholding or withdrawing feedings from patients who currently refuse or previously gave some indication they would refuse artificial nutrition and hydration. This paper investigates under what circumstances nurses feel justified in withholding artificial nutrition and hydration. Structured interviews were conducted with 40 cancer care nurses from two sites, and 40 dementia care nurses from two sites. The interviews were based on two vignettes, one involving an alert patient with terminal cancer, the other a patient suffering end-stage Alzheimer's dementia, and were analysed for themes coinciding with principles of deontological ethics. Investigators found that autonomy, beneficence and non-maleficence most often guided nurses' decisions to withhold or implement artificial feeding.

Arizona↗
PubMed2002

Human cloning and our sense of self.

This Viewpoint formulates and responds to three lines of argument concerning human reproductive cloning's potential to undermine our sense of self or identity. First, cloning would undermine our sense of individuality or uniqueness. But it could only undermine our genetic uniqueness, not our full individuality. Second, cloning would undermine the value or worth of human beings. But it would not make individuals replaceable or of any less moral worth. Third, a clone's freedom or autonomy to construct his or her own life would be undermined by the presence of an earlier twin. But only a mistaken belief in genetic determinism supports this feared loss of freedom.

Cloning, Organism↗
PubMed2004

Pressure and coercion in the care for the addicted: ethical perspectives.

The use of coercive measures in the care for the addicted has changed over the past 20 years. Laws that have adopted the "dangerousness" criterion in order to secure patients' rights to non-intervention are increasingly subjected to critique as many authors plead for wider dangerousness criteria. One of the most salient moral issues at stake is whether addicts who are at risk of causing danger to themselves should be involuntarily admitted and/or treated. In this article, it is argued that the dilemma between coercion on the one hand and abandonment on the other cannot be analysed without differentiated perspectives on the key notions that are used in these debates. The ambiguity these notions carry within care practice indicates that the conflict between the prevention of danger and respect for autonomy is not as sharp as the legal systems seem to imply. Some coercive measures need not be interpreted as an infringement of autonomy--rather, they should be interpreted as a way to provide good care.

Caregivers↗
PubMed1993

Respecting the autonomy of chronic mentally ill women in decisions about contraception.

Treatment of women patients with chronic mental illness who are at risk of unwanted pregnancies presents ethical challenges to the clinician who wishes to respect the patient's autonomy while also helping her avert the potential adverse consequences of unwanted pregnancy. The clinician who simply allows the patient to continue at risk or coerces her into using contraception may not have adequately considered the variable nature of the patient's autonomy. The authors suggest that the clinician should assess and treat conditions underlying the patient's variable impairment of autonomy to maximize her ability to participate in family planning decisions. Case examples are used to illustrate assessment of patients' decision-making capacity, development of family planning approaches that respect patients' autonomy, and use of a newly available contraceptive implant.

Adult↗
PubMed2005

Disclosure of medical errors: ethical considerations for the development of a facility policy and organizational culture change.

The Institute of Medicine report, To Err Is Human: Building a Safer Health System, has spurred public concern over hospitals' ability to deliver safe care. The health care industry continues to struggle to address these concerns. These efforts have driven the growing expectation that health care practitioners or systems disclose unanticipated outcomes to patients and family members. Although the tort system has been cited as an impediment to medical error disclosure, some organizations and systems have successfully implemented policies calling for full disclosure of errors and unanticipated outcomes. However, most organizations have yet to develop policies concerning error disclosure. This article provides an overview of error disclosure and a model framework for an error disclosure policy. The ethical principle of respect for patient autonomy is emphasized as the driving force in developing an institutional disclosure policy and changing the organizational culture to one that supports development and implementation of such a policy.

Ethics, Institutional↗
PubMedDate not supplied

Enough. The failure of the living will.

In pursuit of the dream that patients' exercise of autonomy could extend beyond their span of competence, living wills have passed from controversy to conventional wisdom, to widely promoted policy. But the policy has not produced results, and should be abandoned.

Bioethics↗