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1.  Do patients have duties? 
Journal of Medical Ethics  2007;33(12):689-694.
The notion of patients' duties has received periodic scholarly attention but remains overwhelmed by attention to the duties of healthcare professionals. In a previous paper the author argued that patients in publicly funded healthcare systems have a duty to participate in clinical research, arising from their debt to previous patients. Here the author proposes a greatly extended range of patients' duties grounding their moral force distinctively in the interests of contemporary and future patients, since medical treatment offered to one patient is always liable to be an opportunity cost (however justifiable) in terms of medical treatment needed by other patients. This generates both negative and positive duties. Ten duties—enjoining obligations ranging from participation in healthcare schemes to promoting one's own earliest recovery from illness—are proposed. The characteristics of these duties, including their basis, moral force, extent and enforceability, are considered. They are tested against a range of objections—principled, societal, epistemological and practical—and found to survive. Finally, the paper suggests that these duties could be thought to reinforce a regrettably adversarial characteristic, shared with rights‐based approaches, and that a preferable alternative might be sought through the (here unexplored) notion of a “virtuous patient” contributing to a problem‐solving partnership with the clinician. However, in defining and giving content to that partnership, there is a clear role for most, if not all, of the proposed duties; their value thus extends beyond the adversarial context in which they might first be thought to arise.
doi:10.1136/jme.2007.021188
PMCID: PMC2598206  PMID: 18055897
2.  Ethical reflection on the harm in reproductive decision‐making 
Journal of Medical Ethics  2007;33(12):717-720.
Advances in reproductive technologies continue to present ethical problems concerning their implementation and use. These advances have preoccupied bioethicists in their bid to gauge our moral responsibilities and obligations when making reproductive decisions. The aim of this discussion is to highlight the importance of a sensibility to differences in moral perspective as part of our ethical inquiry in these matters. Its focal point is the work of John Harris, who has consistently addressed the ethical issues raised by advancing reproductive technologies. The discussion is aimed at a central tenet of Harris's position on reproductive decision‐making—namely, that in some instances, giving birth to a worthwhile life may cause harm and will therefore be morally wrong. It attempts to spell out some of the implications of Harris's position that the author takes to involve a misplaced generality. To support this claim, some examples are explored that demonstrate the variety of ways in which concepts (such as harm) may manifest themselves as moral considerations within the context of reproductive decision‐making. The purpose is to demonstrate that Harris's general conception of the moral limits of reproductive autonomy obscures the issues raised by particular cases, which in themselves may reveal important directions for our ethical inquiry.
doi:10.1136/jme.2006.017459
PMCID: PMC2598207  PMID: 18055903
3.  Death's dominion—ethics at the end of life 
Journal of Medical Ethics  2007;33(12):742.
doi:10.1136/jme.2007.021758
PMCID: PMC2598208
4.  The secret art of managing healthcare expenses: investigating implicit rationing and autonomy in public healthcare systems 
Journal of Medical Ethics  2007;33(12):704-707.
Rationing healthcare is a difficult task, which includes preventing patients from accessing potentially beneficial treatments. Proponents of implicit rationing argue that politicians cannot resist pressure from strong patient groups for treatments and conclude that physicians should ration without informing patients or the public. The authors subdivide this specific programme of implicit rationing, or “hidden rationing”, into local hidden rationing, unsophisticated global hidden rationing and sophisticated global hidden rationing. They evaluate the appropriateness of these methods of rationing from the perspectives of individual and political autonomy and conclude that local hidden rationing and unsophisticated global hidden rationing clearly violate patients' individual autonomy, that is, their right to participate in medical decision‐making. While sophisticated global hidden rationing avoids this charge, the authors point out that it nonetheless violates the political autonomy of patients, that is, their right to engage in public affairs as citizens. A defence of any of the forms of hidden rationing is therefore considered to be incompatible with a defence of autonomy.
doi:10.1136/jme.2006.018523
PMCID: PMC2598210  PMID: 18055900
5.  [No title available] 
Journal of Medical Ethics  2007;33(12):736.
PMCID: PMC2598211
6.  The stem cell debate continues: the buying and selling of eggs for research 
Journal of Medical Ethics  2007;33(12):726-731.
Now that stem cell scientists are clamouring for human eggs for cloning‐based stem cell research, there is vigorous debate about the ethics of paying women for their eggs. Generally speaking, some claim that women should be paid a fair wage for their reproductive labour or tissues, while others argue against the further commodification of reproductive labour or tissues and worry about voluntariness among potential egg providers. Siding mainly with those who believe that women should be financially compensated for providing eggs for research, the new stem cell guidelines of the International Society for Stem Cell Research (ISSCR) legitimise both reimbursement of direct expenses and financial compensation for many women who supply eggs for research. In this paper, the authors do not attempt to resolve the thorny issue of whether payment for eggs used in human embryonic stem cell research is ethically legitimate. Rather, they want to show specifically that the ISSCR recommended payment practices are deeply flawed and, more generally, that all payment schemes that aim to avoid undue inducement of women risk the global exploitation of economically disadvantaged women.
doi:10.1136/jme.2007.022129
PMCID: PMC2598212  PMID: 18055905
7.  Teaching medical students about fair distribution of healthcare resources 
Journal of Medical Ethics  2007;33(12):737-741.
Healthcare package decisions are complex. Different judgements about effectiveness, cost‐effectiveness and disease burden influence the decision‐making process. Moreover, different concepts of justice generate different ideas about fair distribution of healthcare resources. This paper presents a decision model that is used in medical school in order to familiarise medical students with the different concepts of justice and the ethical dimension of making concrete choices. The model is based on the four‐stage decision model developed in the Netherlands by the Dunning Committee and the discussion that followed its presentation in 1991. Having to deal with 10 medical services, students working with the model learn to discern and integrate four different ideas of distributive justice that are integrated in a flow chart: libertarian, communitarian, egalitarian and utilitarian.
doi:10.1136/jme.2006.017095
PMCID: PMC2598213  PMID: 18055907
healthcare package; distribution; justice; teaching; decision‐making
8.  [No title available] 
Journal of Medical Ethics  2007;33(12):707.
PMCID: PMC2598214
9.  From cure to palliation: concept, decision and acceptance 
Journal of Medical Ethics  2007;33(12):685-688.
The aim of this paper is to present and discuss nurses' and physicians' comments in a questionnaire relating to patients' transition from curative treatment to palliative care. The four‐page questionnaire relating to experiences of and attitudes towards communication, decision‐making, documentation and responsibility of nurses and physicians and towards the competence of patients was developed and sent to a random sample of 1672 nurses and physicians of 10 specialties. The response rate was 52% (n = 844), and over one‐third made comments. The respondents differed in their comments about three areas: the concept of palliative care, experiences of unclear decision‐making and difficulties in acceptance of the patient's situation. The responses are analysed in terms of four ethical theories: virtue ethics, deontology, consequentialism and casuistry. Many virtues considered to be appropriate for healthcare personnel to possess were invoked. Compassion, honesty, justice and prudence are especially important. However, principles of medical ethics, such as the deontological principle of respect for self‐determination and the consequence of avoidance of harm, are also implied. Casuistry may be particularly helpful in analysing certain areas of difficulty—namely, what is meant by “palliative care”, decision‐making and accepting the patient's situation. Keeping a patient in a state of uncertainty often causes more suffering than necessary. Communication among the staff and with patients must be explicit. Many of the staff have not had adequate training in communicating with patients who are at the end of their life. Time for joint reflection has to be regained, and training in decision‐making is essential. In our opinion, palliative care in Sweden is in need of improvement.
doi:10.1136/jme.2006.018895
PMCID: PMC2598215  PMID: 18055896
cure to palliation; ethical analysis; transition
10.  A software platform to analyse the ethical issues of electronic patient privacy policy: the S3P example 
Journal of Medical Ethics  2007;33(12):695-698.
Paper‐based privacy policies fail to resolve the new changes posed by electronic healthcare. Protecting patient privacy through electronic systems has become a serious concern and is the subject of several recent studies. The shift towards an electronic privacy policy introduces new ethical challenges that cannot be solved merely by technical measures. Structured Patient Privacy Policy (S3P) is a software tool assuming an automated electronic privacy policy in an electronic healthcare setting. It is designed to simulate different access levels and rights of various professionals involved in healthcare in order to assess the emerging ethical problems. The authors discuss ethical issues concerning electronic patient privacy policies that have become apparent during the development and application of S3P.
doi:10.1136/jme.2006.018473
PMCID: PMC2598216  PMID: 18055898
11.  French district nurses' opinions towards euthanasia, involvement in end‐of‐life care and nurse–patient relationship: a national phone survey 
Journal of Medical Ethics  2007;33(12):708-711.
Objectives
To assess French district nurses' opinions towards euthanasia and to study factors associated with these opinions, with emphasis on attitudes towards terminal patients.
Design and setting
An anonymous telephone survey carried out in 2005 among a national random sample of French district nurses.
Participants
District nurses currently delivering home care who have at least 1 year of professional experience. Of 803 district nurses contacted, 602 agreed to participate (response rate 75%).
Main outcome measures
Opinion towards the legalisation of euthanasia (on a five‐point Likert scale from “strongly agree” to “strongly disagree”), attitudes towards terminal patients (discussing end‐of‐life issues with them, considering they should be told their prognosis, valuing the role of advance directives and surrogates).
Results
Overall, 65% of the 602 nurses favoured legalising euthanasia. Regarding associated factors, this proportion was higher among those who discuss end‐of‐life issues with terminal patients (70%), who consider competent patients should always be told their prognosis (81%) and who value the role of advance directives and surrogates in end‐of‐life decision‐making for incompetent patients (68% and 77% respectively). Women and older nurses were less likely to favour legalising euthanasia, as were those who believed in a god who masters their destiny.
Conclusions
French nurses are more in favour of legalising euthanasia than French physicians; these two populations contrast greatly in the factors associated with this support. Further research is needed to investigate how and to what extent such attitudes may affect nursing practice and emotional well‐being in the specific context of end‐of‐life home care.
doi:10.1136/jme.2006.018374
PMCID: PMC2598217  PMID: 18055901
12.  Review of the human fertilisation and embryology act 
Journal of Medical Ethics  2007;33(12):743-744.
doi:10.1136/jme.2007.023523
PMCID: PMC2598218
13.  [No title available] 
Journal of Medical Ethics  2007;33(12):741.
PMCID: PMC2598219
14.  Elderly patients also have rights 
Journal of Medical Ethics  2007;33(12):712-716.
Background
Sharing information with relatives of elderly patients in primary care and in hospital has to fit into the complex set of obligations, justifications and pressures concerning the provision of information, and the results of some studies point to the need for further empirical studies exploring issues of patient autonomy, privacy and informed consent in the day‐to‐day care of older people.
Objectives
To know the frequency with which “capable” patients over 65 years of age receive information when admitted to hospital, the information offered to the families concerned, the person who gives consent for medical intervention, and the degree of satisfaction with the information received and the healthcare provided.
Method
A descriptive questionnaire given to 200 patients and 200 relatives during the patients' stay in hospital.
Results
Only 5% of patients confirmed that they had been asked whether information could be given to their relatives. A significantly higher proportion of relatives received information on the successive stages of the care offered than did patients themselves. As the age of the patients increased, so the number who were given information, understood the information and were asked for their consent for complementary tests decreased. The degree of satisfaction with the information offered was high for both patients and relatives (86.5% and 84%, respectively), despite the irregularities observed.
Conclusions
The capacity of elderly patients to participate in the decision‐making process is frequently doubted simply because they have reached a certain age and it is thought that relatives should act as their representatives. In Spain, the opinion of the family and doctors appears to play a larger role in making decisions than does the concept of patient autonomy.
doi:10.1136/jme.2006.018598
PMCID: PMC2598220  PMID: 18055902
15.  [No title available] 
Journal of Medical Ethics  2007;33(12):731.
PMCID: PMC2598221
16.  [No title available] 
Journal of Medical Ethics  2007;33(12):716.
PMCID: PMC2598222
17.  End‐of‐life decisions in medical practice: a survey of doctors in Victoria (Australia) 
Journal of Medical Ethics  2007;33(12):721-725.
Objectives
To discover the current state of opinion and practice among doctors in Victoria, Australia, regarding end‐of‐life decisions and the legalisation of voluntary euthanasia. Longitudinal comparison with similar 1987 and 1993 studies.
Design and participants
Cross‐sectional postal survey of doctors in Victoria.
Results
53% of doctors in Victoria support the legalisation of voluntary euthanasia. Of doctors who have experienced requests from patients to hasten death, 35% have administered drugs with the intention of hastening death. There is substantial disagreement among doctors concerning the definition of euthanasia.
Conclusions
Disagreement among doctors concerning the meaning of the term euthanasia may contribute to misunderstanding in the debate over voluntary euthanasia. Among doctors in Victoria, support for the legalisation of voluntary euthanasia appears to have weakened slightly over the past 17 years. Opinion on this issue is sharply polarised.
doi:10.1136/jme.2006.017137
PMCID: PMC2598223  PMID: 18055904
euthansia; voluntary; legislation; trends; Australia
18.  More guidelines on research ethics? 
Journal of Medical Ethics  2007;33(12):683-684.
With its new research ethics guidelines, the UK Royal College of Physicians continues a useful tradition of providing guidance to medical researchers.
doi:10.1136/jme.2007.023093
PMCID: PMC2598224  PMID: 18055895
19.  The Declaration of Sydney on human death 
Journal of Medical Ethics  2007;33(12):699-703.
On 5 August 1968, publication of the Harvard Committee's report on the subject of “irreversible coma” established a standard for diagnosing death on neurological grounds. On the same day, the 22nd World Medical Assembly met in Sydney, Australia, and announced the Declaration of Sydney, a pronouncement on death, which is less often quoted because it was overshadowed by the impact of the Harvard Report. To put those events into present-day perspective, the authors reviewed all papers published on this subject and the World Medical Association web page and documents, and corresponded with Dr A G Romualdez, the son of Dr A Z Romualdez. There was vast neurological expertise among some of the Harvard Committee members, leading to a comprehensible and practical clinical description of the brain death syndrome and the way to diagnose it. This landmark account had a global medical and social impact on the issue of human death, which simultaneously lessened reception of the Declaration of Sydney. Nonetheless, the Declaration of Sydney faced the main conceptual and philosophical issues on human death in a bold and forthright manner. This statement differentiated the meaning of death at the cellular and tissue levels from the death of the person. This was a pioneering view on the discussion of human death, published as early as in 1968, that should be recognised by current and future generations.
doi:10.1136/jme.2007.020685
PMCID: PMC2598225  PMID: 18055899
20.  Teaching medical ethics to undergraduate students in post‐apartheid South Africa, 2003–2006 
Journal of Medical Ethics  2007;33(11):673-677.
The apartheid ideology in South Africa had a pervasive influence on all levels of education including medical undergraduate training. The role of the health sector in human rights abuses during the apartheid era was highlighted in 1997 during the Truth and Reconciliation Commission hearings. The Health Professions Council of South Africa (HPCSA) subsequently realised the importance of medical ethics education and encouraged the introduction of such teaching in all medical schools in the country. Curricular reform at the University of Stellenbosch in 1999 presented an unparalleled opportunity to formally introduce ethics teaching to undergraduate students. This paper outlines the introduction of a medical ethics programme at the Faculty of Health Sciences from 2003 to 2006, with special emphasis on the challenges encountered. It remains one of the most comprehensive undergraduate medical ethics programmes in South Africa. However, there is scope for expanding the curricular time allocated to medical ethics. Integrating the curriculum both horizontally and vertically is imperative. Implementing a core curriculum for all medical schools in South Africa would significantly enhance the goals of medical education in the country.
doi:10.1136/jme.2006.018432
PMCID: PMC2598089  PMID: 17971474
21.  [No title available] 
Journal of Medical Ethics  2007;33(11):630.
PMCID: PMC2598090
22.  Faith‐based NGOs and healthcare in poor countries: a preliminary exploration of ethical issues 
Journal of Medical Ethics  2007;33(11):623-626.
An increasing number of non‐governmental organisations (NGOs) provide humanitarian assistance, including healthcare. Some faith‐based NGOs combine proselytising work with humanitarian aid. This can result in ethical dilemmas that are rarely discussed in the literature. The article explores several ethical issues, using four generic activities of faith‐based NGOs: (1) It is discriminatory to deny aid to a needy community because it provides less opportunity for proselytising work. Allocating aid to a community with fewer health needs but potential for proselytising work is unjust, since it neither maximises welfare (utilitarianism) nor assists the most needy (egalitarianism). (2) Faith‐based‐NGOs may state that proselytising work combined with humanitarian assistance improves spiritual wellbeing and overall benefit. However, proselytising work creates religious doubts, which could transiently decrease wellbeing. (3) Proselytising work is unlikely to be a perceived need of the population and, if carried out without consent, breaches the principle of autonomy. Such work also exploits the vulnerability of disaster victims. (4) Governments that decline the assistance of a faith‐based NGO involved in proselytising work may deprive the needy of aid. Three strategies are proposed: (a) Increase knowledge to empower communities, individuals and governments; information on NGOs could be provided through an accessible register that discloses objectives, funding sources and intended spiritual activities. (b) Clearly demarcate between humanitarian aid from proselytising work, by setting explicit guidelines for humanitarian assistance. (c) Strengthen self‐regulation by modifying the Code of Conduct of the Red Cross to state criteria for selecting communities for assistance and procedures for proselytising work.
doi:10.1136/jme.2006.018549
PMCID: PMC2598091  PMID: 17971461
23.  [No title available] 
Journal of Medical Ethics  2007;33(11):662.
PMCID: PMC2598092
24.  Medical ethics on film: towards a reconstruction of the teaching of healthcare professionals 
Journal of Medical Ethics  2007;33(11):678-680.
The clinical vignette remains the standard means by which medical ethics are taught to students in the healthcare professions. Although written or verbal vignettes are useful as a pedagogic tool for teaching ethics and introducing students to real cases, they are limited, since students must imagine the clinical scenario. Medical ethics are almost universally taught during the early years of training, when students are unfamiliar with the clinical reality in which ethics issues arise. Film vignettes fill in that imaginative leap. By providing vivid details with images, film vignettes offer rich and textured details of cases, including the patient's perspective and the clinical reality. Film vignettes provide a detailed ethnography that allows for a more complete discussion of the ethical issues. Film can serve as an additional tool for teaching medical ethics to members of the healthcare professions.
doi:10.1136/jme.2006.017665
PMCID: PMC2598093  PMID: 17971475
25.  Efficiency and the proposed reforms to the NHS research ethics system 
Journal of Medical Ethics  2007;33(11):651-654.
Significant changes are proposed for the research ethics system governing the review of the conduct of medical research in the UK. This paper examines these changes and whether they will meet the aimed‐for goal of improving the efficiency of the research ethics system. The author concludes that, unfortunately, they will not and thus should be rejected.
doi:10.1136/jme.2006.018424
PMCID: PMC2598094  PMID: 17971468
research ethics; NHS research ethics system; proportional review; efficiency; research ethics committees

Results 1-25 (3905)