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PubMed1996

Testing for HIV without specific consent: a short review.

The practice of testing for human immunodeficiency virus (HIV) without the specific knowledge and consent of the patient raises ethical and legal issues. This report argues that diagnostic HIV testing of specific patients, without their consent, is unethical and may also be illegal. Testing for HIV prevalence on an anonymous, unlinked basis, however, is an important aspect of public health surveillance, and the ethics of clinical intervention should not be confused with the ethics of epidemiological research. Specific consent is usually desirable in view of privacy concerns, the importance of patient autonomy, and the potential for conflict of interest. However, where otherwise appropriate, the law should be clarified to permit nonconsensual HIV testing to proceed legally, possibly following scrutiny by an institutional ethics committee.

AIDS Serodiagnosis↗
PubMed1993

Altruism towards the end of life.

In the author's experience most normal healthy adults would like to have the choice of medical help to die if they become incurably ill and find their suffering intolerable. The reasons for this are explored, based on ten years of listening and talking about the subject to a wide variety of people in many countries. The most familiar and common are the avoidance of futile suffering and the desire to retain autonomy. This paper concentrates on the dislike of losing independence and its closely associated wish to continue to behave altruistically. Some reasons for the general lack of recognition of the last two are suggested.

Activities of Daily Living↗
PubMed2004

Ethics of evidence based medicine in the primary care setting.

Evidence based medicine has had an increasing impact on primary care over the last few years. In the UK it has influenced the development of guidelines and quality standards for clinical practice and the allocation of resources for drug treatments and other interventions. It has informed the thinking around patient involvement in decision making with the concept of evidence based patient choice. There are, however, concerns among primary care clinicians that evidence based medicine is not always relevant to primary care and that undue emphasis placed on it can lead to conflict with a clinician's duty of care and respect for patient autonomy. In this paper we consider the impact of evidence based medicine on primary care, and the ethical implications of its increasing prominence for clinicians and managers in primary care.

Decision Making↗
PubMedDate not supplied

Ethical issues in health education.

Moral dilemmas abound during health education practice and ethical decisions have to be made. This article examines the contribution of the four guiding ethical principles (respect for autonomy, beneficence, non-maleficence and justice) to nurse decision making. Multidisciplinary ethical guidelines to assist health educators to serve the best interests of patients and clients are suggested.

Beneficence↗
PubMed2004

[Loss of motivation in dependent elderly subjects].

Loss of motivation differs from a mood disorder. It belongs to the field of psychic regression and results in social dependency. The concept of psychic regression, initiated and driven by a motivation loss, requires a reassessment of the family links and of the patients-carers relationships. The relative part of conative depression, dysexecutive syndrome, and psychic regression is difficult to assess in old subjects on account of the complexity of the involved mechanisms (psychological aging, affective and relational history of the subject, family and environmental interactions). Lack of motivation and social dependency in old people result from a failure of the psychological mechanism of elaboration. We present a phenomenological point of view and advance some propositions for their prevention. Loss of motivation appears to be an acquired and dynamic process resulting from the psychological difficulties experienced by the individual due to the loss of autonomy and an increasing dependency which is not accepted although, paradoxically, searched for. This ambivalence results in loss of motivation and psychic regression which belongs to the non cognitive disorders of elderly people.

Affect↗
PubMed2003

Autonomy as a universal expectation: a review and a research proposal.

In the World Health Report 2000 WHO introduces ethical issues in the elevation of health systems responsiveness performance. Although we consider this a positive step, the parameters considered in the Report are in some cases unsustained by extensive research. This is the case of autonomy, which is postulated as a "universal expectation". As we think that this is culture-linked issue we argue that such kind of universal categorizations lacks substantive empirical evidence. We undertook a short review of a small intentional sample of international literature, in order to demonstrate that regardless of the philosophical status of autonomy as a principle or category there is not background enough to postulate it as a universal expectation. We propose international collaborative research to define the issue, using qualitative research methodology.

Cross-Cultural Comparison↗
PubMedDate not supplied

Health care decisionmaking by children. Is it in their best interest?

The argument for children's rights in health care has been long in the making. The success of this position is reflected in the 1995 American Academy of Pediatrics recommendations for the role of children in health care decisionmaking, which suggest that children be given greater voice as they mature. But there are good moral and practical reasons for exercising caution in these health care situations, especially when the child and parents disagree. Parents need the moral and legal space within which to make decisions that will facilitate their child's long-term autonomy, not only her present-day autonomy. Moreover, third-party intrusion, by physicians or the state, should be resisted unless negligent and abusive decisions are in the making.

Child↗
PubMed2004

Current legal status of advance directives in the United States.

Advance directive legislation has been in place throughout much of the United States for nearly 3 decades. The right to give an informed consent to or refusal of medical treatment has been recognized by state and federal courts, and that right has been determined to survive the loss of decisional capacity and may be exercised through the execution of instructional or proxy directives. Despite these developments, the percentage of the adult population with a formal advance directive of any type has never exceeded 15%. Moreover, a remarkable number of these directives are ambiguous and/or their existence is unknown to the physicians who are expected to rely upon them. Even unambiguous directives may not be followed at the critical stage in the trajectory of a patient's illness, and the accountability for such disregard by health care institutions or professionals is negligible to nonexistent. Nevertheless, there is real potential for advance directives, as a key element to sound advance care planning, to fulfill their initial promise as instruments of the prospective autonomy of patients. In order for that potential to be realized, primary care physicians must embrace advance care planning as a part of their professional responsibility to patients.

Advance Directives↗
PubMed1996

An ethically justified algorithm for offering, recommending, and performing cesarean delivery and its application in managed care practice.

When cesarean delivery is substantively supported and vaginal delivery is not supported in beneficence-based clinical judgment, the physician should offer and recommend only cesarean delivery. When both cesarean and vaginal delivery are substantively supported in beneficence-based clinical judgment, the physician should offer both, discuss any controversy, and make a recommendation. When cesarean delivery is substantively supported and vaginal delivery is more substantively supported in beneficence-based clinical judgment, the physician should offer both and recommend vaginal delivery. If cesarean delivery is not supported and vaginal delivery is substantively supported in beneficence-based clinical judgment, the physician should offer only vaginal delivery. When cesarean delivery is requested and well supported solely in autonomy-based clinical judgment, the physician should repeat the recommendation for vaginal delivery and either perform cesarean delivery or make a referral. Physicians may use this algorithm in negotiating managed care contracts.

Algorithms↗
PubMed2005

Self-determination and conflict in romantic relationships.

Four studies examined associations between E. L. Deci and R. M. Ryan's (1985, 2000) construct of autonomy, responses to relationship disagreements, and dissatisfaction after conflict. In Study 1, diary data showed that trait autonomy predicted relationship autonomy, which in turn predicted relative satisfaction after disagreements. In Study 2, trait autonomy predicted relationship autonomy, which was associated with less defensive and more understanding responses to conflict. Studies 3 and 4 examined whether one's partner's relationship autonomy uniquely predicted reported and observed behavior during conflict. Autonomous reasons for being in the relationship (of both self and partner) predicted both reported and observed responses to conflict and feelings of satisfaction.

Adult↗
PubMed1999

Hope and deception.

Convinced of hope's therapeutic benefits, physicians routinely support patients' false hopes, often with family collusion and vague, euphemistic diagnoses and prognoses, if not overt lies. Bioethicists charge them with paternalistic violations of Patient Autonomy. There are, I think, too many morally significant exceptions to accept the physician's rationales, or the bioethicist's criticisms, stated sweepingly. Physicians need to take account of the harms caused by loss of hopes, especially false hopes due to deception, as well as of the harms of successfully maintained deceptive hopes. As for autonomy, hopes -- even if based on deception -- can protect and enhance autonomy, understood broadly as the capacity to lead a chosen or embraced life. Deception aside, patients' hopes often rest on beliefs about possible rather than probable outcomes -- beliefs themselves supported by optimism, 'denial', or self-deception. Such 'possibility-hopes' may conflict with physicians' often more fact-sensitive 'probability hopes.' To resolve such conflicts physicians may try to 'down-shift' patients' or parents' hopes to lesser, more realistic hopes. Alternatively, physicians may alter or enlarge their own professional hopes to include the 'vital hopes' that define the lives of patients or parents, as well as 'survival hopes' needed to face and bear the loss of loved ones, especially children. A principle of Hope-giving might help guide such sympathetic hope-accommodations. More generally, it would give Hope a distinct place among Beneficence, Autonomy, and the other moral factors already highlighted by canonical principles of Medical Ethics. To formulate such a principle, however, we will need a collective Project Hope to pursue deeper philosophical and psychological studies.

Altruism↗
PubMed1989

A vote for no confidence.

This paper considers the justifications for adhering to a principle of confidentiality within medical practice. These are found to derive chiefly from respect for individual autonomy, the doctor/patient contract, and social utility. It is suggested that these will benefit more certainly if secrecy is rejected and the principle of confidentiality is removed from the area of health care.

Codes of Ethics↗
PubMed1995

Best interests: a concept analysis and its implications for ethical decision-making in nursing.

The purpose of this paper is to analyse the concept of 'best interest' in order to give nurses, who use it to justify their actions, a clear picture of what this means, and to identify the skills needed for doing so. The process for concept analysis developed by Walker and Avant was used in the analysis of data generated from the literature. Themes were identified from which the defining attributes, antecedents and consequences emerged. The congruence of the findings with current values in nursing, such as promotion of patient autonomy, and the nurse as advocate, are discussed, together with the underpinning ethics theory. The skills needed for nursing practice are identified and recommendations for nurse education are made.

Beneficence↗
PubMed2006

Decision making in acute care: a practical framework supporting the 'best interests' principle.

The best interests principle is commonly utilized in acute care settings to assist with decision making about life-saving and life-sustaining treatment. This ethical principle demands that the decision maker refers to some conception of quality of life that is relevant to the individual patient. The aim of this article is to describe the factors that are required to be incorporated into an account of quality of life that will provide a morally justifiable basis for making a judgement about the future quality of life, and therefore the best interests, of critically ill patients who are mentally incompetent. This account consists of three major components pain and suffering, body functioning, and autonomy and is applicable in situations where very limited information is available to guide decision making. This framework helps to make decisions about the provision of life-saving treatment that are as consistent as possible in all patient situations.

Decision Making↗
PubMedDate not supplied

[Participation and autonomy of mothers in the care of the hospitalized child].

This is a qualitative study whose purpose was to check with mothers the meaning and significance of remaining in the hospital and their participation and autonomy in the care of the hospitalized child. The field research was carried out through participant observation and through interviews with mothers. The inclusion of the mother in the care of the child has been taking place in a subtle way, and the mother has been taking on procedures which nurses were formerly in charge of, concentrating information about the therapeutic process. Nurses establish a hierarchical relation of domination-subordination with the mothers, who create some autonomy breaks in everyday situations. The lack of a collective therapeutic project in a perspective of care focused on the family is one of the obstacles to the involvement of the mother in the assistance.

Child↗
PubMed2003

Harm as the price of liberty? Pre-implantation diagnosis and reproductive freedom.

Reproductive autonomy is often used as an argument to offer assisted reproduction services to women and to continue research into improving this service. What is often overlooked, however, is the gendered and normative background of parenthood, especially of motherhood. In this paper, I attempt to make women visible and to listen to their voices. Turning to the women's stories, the ethical perspective might be reversed: the so-called 'side-effects' of the overall successful assisted reproduction with or without genetic diagnosis, are to be considered the 'main effects' of assisted reproduction--true for the majority of couples and women. Autonomy, then, must be reformulated as concept of moral agency in the context of divergent social contexts and cultures of parenthood, of socially shaped images of disability, and in the context of scientific visions of technology which do not necessarily match with the medical practice.

Female↗
PubMed1994

Futility, autonomy, and informed consent.

If clinicians deem a treatment medically futile, is it appropriate to mention such a treatment to patients? Do healthcare professionals violate informed consent if they do not offer patients an opportunity to decline futile treatments? The notion of futility involves an assessment of patient best interest--both short-term and long-term therapeutic benefit for a patient and the community in which he or she intends to survive and flourish. Although survival interests may be construed as long term, a treatment that offers survival without any promise of flourishing is not the goal of medicine and is futile. Flourishing requires some cognitive and affective function. The goal of informed consent practices is to ensure that patients accept the benefits of treatment with cognizance of the burdens and risks. Given the impact of illness on the emotional and psychological states of patients and their families and their resultant vulnerability, the omission of futile options from treatment plans is logical and exemplifies the best of paternalistic behavior. The claim that requests for futile treatment must be honored is based on a perverse understanding of patient autonomy. Rational medicine demands that patients' requests be reasonable from a clinical perspective, as well as from a subjective one. The practice of informed consent can be implemented as a balance between these two interests.

Disclosure↗