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Choose this option if your instructor will require Connect to be used in the course. This binder-ready, loose-leaf version includes free shipping. She taught at the College of Wooster before moving to the Department of Philosophy at the University at Albany A Fellow of the Hastings Center since , she has participated in many of its working groups. Alex John London is the Clara L. He is a philosopher who writes about ethical issues in the development and deployment of novel technologies in fields from medicine and public health to artificial intelligence.
He also writes about foundational issues in Kantian and Aristotelian ethics and about issues of justice and fairness in both domestic and international contexts. Customer Reviews, including Product Star Ratings help customers to learn more about the product and decide whether it is the right product for them.
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In the absence of such clear evidence of consent, physicians and other hospital staff are often reluctant to ask bereaved family members for donations because many people, understandably, cannot deal with such a request in a time of crisis. Should the United States adopt a policy—already practiced in other countries—of allowing hospitals to harvest organs upon the death of a patient unless that person has specified otherwise? Would therapeutic cloning or xenotransplantation provide ethically preferable alternatives?
She is between jobs and is about to apply for a position with a small, innovative firm that has a self-insured health care plan. She knows that the disclosure of this information would dramatically skew the insurance risk and insurance costs for this company, which is largely composed of young people who have relatively low health care costs. She might be denied the job for these reasons. The patient wants to undergo BRCA screening but asks you not to note the results in her medical record.
You know that her fears are well founded. What should you do? These examples highlight the complexity of ethical dilemmas and the need for a common language by which clinicians and society can openly deliberate about ethical issues. Often, there is not a single right answer to an ethical dilemma; in almost all cases, there are competing values that need to be weighed against each other before a decision is made that most fully upholds the moral values by which physicians must guide their practice.
As in many other areas of medicine, there may be a high degree of uncertainty. For that reason alone, it is useful to have a framework for ethical decision making. A conflict of values lies at the center of each ethical dilemma. Most medical ethicists agree that several fundamental ethical norms can be drawn from the overarching principle that patients should be treated with respect.
These ethical norms include the responsibility to act in a way that benefits the patient beneficence ; the responsibility, whenever possible, to do no harm nonmaleficence ; the responsibility to acknowledge the autonomy of the patient and his or her right to self-determination; and the responsibility to treat people fairly and equitably. Although it would be hard to argue against any of these values taken individually, they come into conflict with one another every day in medical practice.
Three steps are useful for making decisions when ethical conflicts arise. First, the clinician needs to gather all available relevant information regarding the patient. Inadequate information can result in decisions that do not reflect the interests and desires of the patient.
Second, ethical dilemmas must be clarified and presented clearly to all those involved in the decision-making process. For example, a spouse of an incompetent patient who argues for aggressive, clinically futile treatment in the face of an imminently terminal and untreatable illness can present the physician with a conflict between respecting the considered wishes of family members and doing what the physician judges is best for the patient. It is often helpful to involve other physicians or nonphysician mediators, such as the hospital ethicists, patient advocates, social workers, and clergy members, in the decision-making process.
Three broad societal concerns that have important implications for clinical practice lie at the center of many current ethical dilemmas. Modern medicine has been criticized for generating an ethos in which clinicians assume that if an intervention is available, it should always be used. A physician might offer a new intervention as a way of either sustaining hope for the patient and family or avoiding the reality of a poor prognostic situation. In these circumstances, the chances of success can sometimes be overestimated.
There are times when the better course is to help patients and families deal realistically with their losses. Current research in genetics, for example, challenges traditional assumptions of the uniqueness of individual identity and the acceptability of genetic interventions. However, research has now progressed to the point of growing human stem cells under laboratory conditions, and stem cell research is thought to be one of the most promising new areas for clinical interventions.
This shift has occurred in part because stem cell techniques do not create permanent germline changes. Scientific research is ongoing, especially in other countries18; in the United States, interest in the clinical promise of stem cell technology continues to grow.
Legislators in California and Massachusetts have created and funded state-level research centers, and other states are considering whether to undertake similar initiatives. Attempts to promulgate practice guidelines for governing the conduct of stem cell research engender extensive debate; such debate generates rich ethical discourse that addresses the very essence of personhood.
Reproductive technologies, including the potential for cloning, have an impact on this issue and have spurred new questions about the ethics of medical intervention in human reproduction. The debate about abortion in the United States continues to encompass many points of controversy that directly affect the practice of medicine, sometimes violently. At the other end of the continuum of care is the question of when life ends. This question is brought into sharp focus by dramatic life-extending technologies.
For example, although rational criteria for brain death have served to guide organ transplantation, the extreme shortage of donor organs and evolving technological capabilities have prompted new ethical considerations regarding organ recovery.
As utilization of organ donations from non-brain-dead but irreversibly comatose persons has become an increasingly common practice, commitment to clarifying and addressing the ethical dilemmas associated with the use of such donors remains warranted. Discussions of quality of life gain broader clinical relevance as technical advances make it easier to extend life beyond a point where many people would consider it meaningful.
When a patient or family member raises the issue, it is important for the physician to learn more about what that person means by "quality of life. Often, the phrase is used in the context of how long clinicians should continue attempts to extend life. The ideal setting for gathering this key information is in an ongoing caregiving relationship that allows the patient time to think about the issues, discuss them with those close to him or her, and come back to the physician for a fuller discussion.
Crucial decisions must often be made among relative strangers in times of great stress for example, in an intensive care unit or when the patient is on the brink of having a cardiac arrest precipitated by critical illness. For that reason, physicians should try to open the door to these discussions with patients ahead of time whenever appro-priate. In general, questions related to acceptable quality of life should be answered by the patient.
In addition to providing clear information about prognosis and likely outcomes, it is important for the clinician to recognize that a proxy is in a very difficult position—often in the midst of acute grief or anx-iety—and should be provided a comforting context in which to make a decision.
A proxy should not be made to feel that he or she is alone in making this decision, especially in the common situation in which the patient is likely to die in any case. Written advance directives—so-called living wills—can be helpful in this regard, mostly as adjuncts to discussions between patient and physician. Assigning a trusted proxy is still recommended, however, because situations are often more complex than can be adequately addressed in a written document.
One of the reasons the medical profession has been able to maintain a strong ethical standard for more than 2, years is that the standard has been so simple. Admittedly, there have been breaches of the standard. Many physicians became rich selling unproven patent medicines before the advent of scientific medicine. More recently, some have overcharged patients or have ordered unnecessary tests, medications, and procedures to further their own financial interests.
Overtreatment can be as unethical as undertreatment, for two reasons: 1 all treatments carry some degree of risk to the patient and 2 rising health care costs contribute to the difficulty our nation faces in extending health care access to the uninsured and underinsured. Physicians have a responsibility for societal health, as well as the health of their individual patients. In the past, the accountability structure for health care was clearly delineated between physician and patient.
Today, changes in the economics and delivery systems of managed care have so affected this classic ethical construct of undivided loyalty to the patient that even previously inviolable ethical relationships are being challenged. Managed care has been criticized for withholding care from patients , and physicians have been seen as the agents of rich insurance companies rather than as advocates for the best health care for their patients.
Good managed care, however, allows physicians to limit risk to patients and reduce waste and cost. Such measures are imperfect but will reveal to patients and others standards for ideal care. How should physicians respond to these new demands for transparency? Understanding the fundamental responsibility of the profession to the welfare of the patient is an important starting point for dealing with any ethical problems arising from social change, technological innovation, and changes in the delivery and financing of health care.
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