9780073129556

Preface

Introduction: Medicine and Moral Arguments

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PART 1 MEDICAL DECISION MAKING

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Issue 1. Is Informed Consent Still Central to Medical Ethics?

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YES: Robert M. Arnold and Charles W. Lidz, from "Informed Consent: Clinical Aspects of Consent in Health Care," in Stephen G. Post, ed., Encyclopedia of Bioethics, vol. 3, 3rd ed. (Macmillan, 2003)

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NO: Onora O'Neill, from Autonomy and Trust in Bioethics (Cambridge University Press, 2002)

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Physician Robert M. Arnold and professor of psychiatry and sociology Charles W. Lidz assert that informed consent in clinical care is an essential process that promotes good communication and patient autonomy despite the obstacles of implementation. Philosopher Onora O'Neill argues that the most evident change in medical practice in recent decades may be a loss of trust in physicians rather than any growth of patient autonomy. Informed con-sent in practice, she says, often amounts simply to a right to choose or refuse treatments, not a deeper and more meaningful expression of self-mastery.

Issue 2. Can Family Interests Ethically Outweigh Patient Autonomy?

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YES: John Hardwig, from "What About the Family?" Hastings Center Report (March-April 1990)

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NO: Jeffrey Blustein, from "The Family in Medical Decision-making," Hastings Center Report (May June 1993)

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John Hardwig, an associate professor of medical ethics, argues that the prevalent ethic of patient autonomy ignores family interests in medical treatment decisions. He maintains that physicians should recognize these interests as legitimate. Bioethicist Jeffrey Blustein contends that although families can be an important resource in helping patients make better decisions about their care, the ultimate decision-making authority should remain with the patient.

Issue 3. Does Direct-to-Consumer Advertising of Medication Enhance Patient Autonomy?

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YES: Alan F. Holmer, from "Direct-to-Consumer Prescription Drug Advertising Builds Bridges Between Patients and Physicians," Journal of the American Medical Association (January 27, 1999)

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NO: Matthew F. Hollon, from "Direct-to-Consumer Marketing of Prescription Drugs," Journal of the American Medical Association (January 27, 1999)

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Alan F. Holmer, an attorney and head of the Pharmaceutical Research and Manufacturers of America, argues that advertising of medication empowers consumers by educating them about health conditions and possible treatments. Matthew F. Hollon, a physician, believes that advertising of medication is designed to increase consumer demand, rather than for educational purposes, and has little public health value.

PART 2 DEATH AND DYING

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Issue 4. Are Some Advance Directives Too Risky for Patients?

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YES: Christopher James Ryan, from Betting Your Life: An Argument Against Certain Advance Directives, Journal of Medical Ethics (vol. 22, 1996)

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NO: Steven Luttrell and Ann Sommerville, from "Limiting Risks by Curtailing Rights: A Response to Dr. Ryan," Journal of Medical Ethics (vol. 22, 1996)

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Psychiatrist Christopher James Ryan argues that advance directives that refuse active treatment in situations when a patient's incompetence is potentially reversible should be abolished because healthy people are likely to underestimate their desire for treatment should they become ill. Geriatricians Steven Luttrell and Ann Sommerville assert that respect for the principle of autonomy requires that individuals be permitted to make risky choices about their own lives and that ignoring autonomous choices made by competent adults reinstates the outmoded notion of medical paternalism.

Issue 5. Should Physicians Be Allowed to Assist in Patient Suicide?

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YES: Marcia Angell, from "The Supreme Court and Physician-Assisted Suicide-The Ultimate Right," The New England Journal of Medicine (January 2, 1997)

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NO: Kathleen M. Foley, from "Competent Care for the Dying Instead of Physician-Assisted Suicide," The New England Journal of Medicine (January 2, 1997)

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Physician Marcia Angell asserts that a physician's main duties are to respect patient autonomy and to relieve suffering, even if that sometimes means assisting in a patient's death. Physician Kathleen M. Foley counters that if physician-assisted suicide becomes legal, it will begin to substitute for interventions that otherwise might enhance the quality of life for dying patients.

Issue 6. Should Truth-Telling Depend on the Patient's Culture?

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YES: Leslie J. Blackhall, Gelya Frank, Sheila Murphy, and Vicki Michel, from "Bioethics in a Different Tongue: The Case of Truth-Telling," Journal of Urban Health (March 2001)

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NO: Mark Kuczewski and Patrick J. McCruden, from "Informed Consent: Does It Take a Village? The Problem of Culture and Truth Telling," Cambridge Quarterly of Healthcare Ethics (2001)

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Leslie J. Blackhall (currently at the University of Virginia), Gelya Frank and Sheila Murphy, from the University of Southern California, and Vicki Michel, from the Loyola Law School, advise clinical and bioethics professionals facing truth-telling dilemmas to make room for the diverse ethical views of the populations they serve. Philosopher Mark Kuczewski and bioethicist Patrick J. McCruden argue that by insisting on informed consent or an appropriate waiver process, the health care system respects cultural differences rather than stereotyping them.

Issue 7. Should Doctors Be Able to Refuse Demands for "Futile" Treatment?

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YES: Steven H. Miles, from "Informed Demand for 'Non-Beneficial Medical Treatment," The New England Journal of Medicine (August 1 1991)

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NO: Felicia Ackerman, from "The Significance of a Wish," Hasting Center Report (July-August 1991)

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Physician Steven H. Miles maintains that physicians' duty to follow patients' wishes ends when the requests are inconsistent with what medical care can reasonably be expected to achieve, when they violate community standards of care, and when they consume an unfair share of collective resources. Philosopher Felicia Ackerman contends that it is ethically inappropriate for physicians to decide what kind of life is worth prolonging and that decisions involving personal values should be made by the patient or family.

PART 3 CHOICES IN REPRODUCTION

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Issue 8. Is Abortion Immoral?

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YES: Patrick Lee and Robert P. George, from "The Wrong of Abortion," in Andrew Cohen and Christopher Hea Wellman, eds., Contemporary Debates in Applied Ethics (Blackwell, 2005)

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NO: Margaret Olivia Little, from "The Morality of Abortion," in Bonnie Steinbock, John D. Arras, and Alex John London, eds., Ethical Issues in Modern Medicine (McGraw-Hill, 2003)

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Philosopher Patrick Lee and professor of jurisprudence Robert P. George assert that human embryos and fetuses are complete (though immature) human beings and that intentional abortion is unjust and objectively immoral. Philosopher Margaret Olivia Little believes that the moral status of the fetus is only one aspect of the morality of abortion. She points to gestation as an intimacy, motherhood as a relationship, and creation as a process to advance a more nuanced approach.

Issue 9. Should Pregnant Women Be Punished for Exposing Fetuses to Risk?

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YES: Jean Toal, from Majority Opinion, Cornelia Whitner, Respondent, v. State of South Carolina, Petitioner (July 15, 1997)

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NO: Lynn M. Paltrow, from "Punishment and Prejudice: Judging Drug-Using Pregnant Women," in Julia E. Hanigsberg and Sara Ruddick, eds., Mother Troubles: Rethinking Contemporary Maternal Dilemmas (Beacon Press, 1999)

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In a case involving a pregnant woman's use of crack cocaine, a majority of the supreme court of South Carolina ruled that a state legislature may impose additional criminal penalties on pregnant drug-using women without violating their constitutional right of privacy. Attorney Lynn M. Paltrow argues that treating drug-using pregnant women as criminals targets poor, African American women while ignoring other drug usage and fails to provide the resources to assist them in recovery.

PART 4 CHILDREN AND BIOETHICS

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Issue 10. Should Adolescents Make Their Own Life-and-Death Decisions?

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YES: Robert F. Weir and Charles Peters, from "Affirming the Decisions Adolescents Make About Life and Death," Hastings Center Report (November-December 1997)

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NO: Lainie Friedman Ross, from "Health Care Decisionmaking by Children: Is It in Their Best Interest?" Hastings Center Report (November-December 1997)

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Ethicist Robert F. Weir and pediatrician Charles Peters assert that adolescents with normal cognitive and developmental skills have the capacity to make decisions about their own health care. Advance directives, if used appropriately, can give older pediatric patients a voice in their care. Pediatrician Lainie Friedman Ross counters that parents should be responsible for making their child's health care decisions. Children need to develop virtues, such as self-control, that will enhance their long-term, not just immediate, autonomy.

Issue 11. Do Parents Harm Their Children When They Refuse Medical Treatment on Religious Grounds?

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YES: Massachusetts Citizens for Children, from "Death by Religious Exemption,"http://www.masskids.org/dbre/dbre_1.html (January 1992)

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NO: Mark Sheldon, from "Ethical Issues in the Forced Transfusion of Jehovah's Witness Children," The Journal of Emergency Medicine (vol. 14, no. 2, 1996)

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Massachusetts Citizens for Children, an advocacy organization, asserts that laws exempting parents from responsibility to provide medical care for their seriously ill children, on the basis of religious beliefs, result in needless deaths and mislead parents about their legal responsibilities. Professor of philosophy Mark Sheldon assesses the case of Jehovah's Witness parents who refuse to allow their children to undergo blood transfusions and concludes that they cannot be said to be truly harming or neglecting their children. Rather, they are placing their children's spiritual interests above worldly ones.

PART 5 GENETICS

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Issue 12. Should the Federal Government Fund Human Stem Cell Research?

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YES: David Baltimore, from "Don't Impede Medical Progress," The Wall Street Journal (July 30, 2001)

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NO: George W. Bush, from "Remarks by President George W. Bush on Stem Cell Research," Monitoring Stem Cell Research: A Report of the President's Council on Bioethics (January 2004)

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David Baltimore, president of the California Institute of Technology and a Nobel Prize winner, believes that promising stem cell research should not be impeded by a view that considers a tiny mass of cells that has never been in a uterus as a human being. President George W. Bush opposes creating new stem cell lines with federal funds because he believes that it would devalue human life.

Issue 13. Will Genetic Testing Lead to Denial of Insurance and Employment?

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YES: Maurie Markman, from "Genetic Discrimination Arising from Cancer Risk Assessments: A Societal Dilemma," Cleveland Clinic Journal of Medicine (January 2004)

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NO: Nancy L. Fisher, from "Genetic Testing and Health Insurance: Can They Coexist?" Cleveland Clinic Journal of Medicine (January 2004)

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Cancer physician Maurie Markman fears that genetic knowledge will be used to deny insurance or employment to people who, on the basis of their genes, are at increased risk of developing major diseases. He argues that insurers should not be permitted under any circumstances to use genetic information to deny medical coverage. Physician Nancy L. Fisher, who is a member of the Human Genome Project's committee on ethical, legal, and social implications, looks to legislation to sort out how much information insurance companies should be able to obtain. Insurance companies are businesses, she says, and businesses have to function appropriately to survive.

PART 6 HUMAN AND ANIMAL EXPERIMENTATION

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Issue 14. Should Animal Experimentation Be Permitted?

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YES: Jerod M. Loeb, et al., from "Human vs. Animal Rights: In Defense of Animal Research," Journal of the American Medical Association (November 17, 1989)

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NO: Tom Regan, from "Ill-Gotten Gains," in Donald Van DeVeer and Tom Regan, eds., Health Care Ethics: An Introduction (Temple University Press, 1987)

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Jerod M. Loeb and his colleagues, representing the American Medical Association's Group on Science and Technology, assert that concern for animals, admirable in itself, cannot impede the development of methods to improve the welfare of humans. Philosopher Tom Regan argues that conducting research on animals exacts the grave moral price of failing to show proper respect for animals' inherent value, whatever the benefits of the research.

Issue 15. Is Sham Surgery Ethically Acceptable in Clinical Research?

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YES: Thomas B. Freeman, et al., from "Use of Placebo Surgery in Controlled Trials of a Cellular-Based Therapy for Parkinson's Disease," The New England Journal of Medicine (September 23, 1999)

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NO: Ruth Macklin, from "The Ethical Problems with Sham Surgery in Clinical Research," The New England Journal of Medicine (September 23, 1999)

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Physician Thomas B. Freeman and his colleagues contend that their study of fetal-tissue transplantation, which used imitation, or sham, surgery in one group of patients, will establish whether this treatment is beneficial or not. Furthermore, this treatment will benefit thousands of patients with Parkinson's disease if proven effective. Philosopher Ruth Macklin concludes that sham surgery is ethically unacceptable, particularly in the case of fetal-tissue transplantation, because it does not minimize harm to subjects, a fundamental principle underlying research ethics.

PART 7 BIOETHICS AND PUBLIC POLICY

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Issue 16. Should Health Insurance Be Based on Employment?

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YES: William S. Custer, Charles N. Kahn III, and Thomas F. Wildsmith IV, from "Why We Should Keep the Employment-Based Health Insurance System," Health Affairs (November/ December 1999)

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NO: Uwe E. Reinhardt, from "Employer-Based Health Insurance: A Balance Sheet," Health Affairs (November/ December 1999)

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Insurance and policy analysts William S. Custer, Charles N. Kahn III, and Thomas F. Wildsmith IV assert that the employment-based health care system in the United States offers a solid, proven foundation on which to base any reform, and that attempts to break the link between employment and health insurance coverage may greatly increase the number of uninsured Americans. Economist Uwe E. Reinhardt argues that, on balance, the debits of the employer-based health insurance system outweigh the credits, and that a parallel system detached from the workplace could eventually absorb the current system.

Issue 17. Does Military Necessity Override Medical Ethics?

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YES: Michael L. Gross, from "Bioethics and Armed Conflict: Mapping the Moral Dimensions of Medicine and War," Hastings Center Report (November/December 2004)

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NO: M. Gregg Bloche and Jonathan H. Marks, from "When Doctors Go to War," New England Journal of Medicine (January 6, 2005)

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Political scientist Michael L. Gross argues that war brings military and medical values into conflict, and that military necessity often overwhelms a physician's other moral obligations, such as relieving suffering. M. Gregg Bloche, a physician and lawyer, and Jonathan H. Marks, a British barrister, stress that physicians remain physicians even in the military and that there is an urgent moral challenge in managing the conflict, not denying it.

Issue 18. Should Performance-Enhancing Drugs Be Banned from Sports?

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YES: Thomas H. Murray, from "Drugs, Sports, and Ethics," Project Syndicate (July 2004)

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NO: Julian Savulescu, Bennett Foddy, and Megan Clayton, from "Why We Should Allow Performance Enhancing Drugs in Sport," British Journal of Sports Medicine (December 2004)

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Social psychologist Thomas H. Murray contends that performance-enhancing drugs affect the individual athlete's integrity because using banned substances is a dishonest behavior and corrupts a victory. Philosopher Julian Savulescu and research colleagues Bennett Foddy and Megan Clayton argue that legalizing drugs in sport may be fairer and safer than banning them.

Issue 19. Should There Be a Market in Body Parts?

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YES: J. Radcliffe-Richards, et al., from "The Case for Allowing Kidney Sales," The Lancet (June 27, 1998)

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NO: David J. Rothman, from "The International Organ Traffic," The New York Review of Books (March 26, 1998)

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Philosopher J. Radcliffe-Richards and colleagues of the International Forum for Transplant Ethics contend that bans on selling organs remove the only hope of the destitute and the dying. Arguments against selling organs are weak attempts to justify the repugnance felt by people who are rich or healthy. Historian David J. Rothman asserts that trafficking in organs for transplantation is motivated by greed and subverts the ethical principles of the medical profession.

Issue 20. Should Pharmacists Be Allowed to Deny Prescriptions on Grounds of Conscience?

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YES: Donald W. Herbe, from "The Right to Refuse: A Call for Adequate Protection of a Pharmacist's Right to Refuse Facilitation of Abortion and Emergency Contraception," Journal of Law and Health (2002/2003)

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NO: Julie Cantor and Ken Baum, from "The Limits of Conscientious Objection-May Pharmacists Refuse to Fill Prescriptions for Emergency Contraception?" New England Journal of Medicine (November 4, 2004)

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Law student Donald W. Herbe asserts that pharmacists' moral beliefs concerning abortion and emergency contraception are genuinely fundamental and deserve respect. He proposes that professional pharmaceutical organizations lead the way to recognizing a true right of conscience, which would eventually result in universal legislation protecting against all potential ramifications of choosing conscience. Julie Cantor, a lawyer, and Ken Baum, a physician and lawyer, reject an absolute right to object, as well as no right to object, to these prescriptions but assert that pharmacists who cannot or will not dispense a drug have a professional obligation to meet the needs of their customers by referring them elsewhere.

Issue 21. Should Public Health Be Given Sweeping Powers Over Individual Liberty in a Bioterrorist Threat?

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YES: Lawrence O. Gostin, from "Law and Ethics in a Public Health Emergency," Hastings Center Report (March-April 2002)

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NO: George J. Annas, from "Bioterrorism, Public Health, and Human Rights," Health Affairs (November/December 2002)

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Law and public health professor Lawrence O. Gostin states that the threat of bioterrorism makes it imperative to reframe the balance between individual interests and society's need to protect itself so that the common good prevails. Law professor George J. Annas contends that taking human rights seriously is our best defense against terrorism and fosters public health on both a federal and global scale.

Contributors

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Index

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