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In a two-stage survey, a cross-section of Australians were questioned about the importance of costs in setting priorities in health care. Generally, respondents felt that it is unfair to discriminate against patients who happen to have a high cost illness and that costs should therefore not be a major factor in prioritising. The majority maintained this view even when confronted with its implications in terms of the total number of people who could be treated and their own chance of receiving treatment if they fall ill. Their position cannot be discarded as irrational, as it is consistent with a defensible view of utility. However, the results suggest that the concern with allocative efficiency, as usually envisaged by the economists, is not shared by the general public and that the cost-effectiveness approach to assigning priorities in health care may be imposing an excessively simple value system upon resource allocation decision-making.

To give priority to the young over the elderly has been labelled `ageism'. People who express "ageist" preferences may feel that, all else equal, an individual has a greater right to enjoy additional life years the fewer life years he or she has already had. We shall refer to this as egalitarian ageism. They may also emphasise the greater expected duration of health benefits in young people that derives from their greater life expectancy. We may call this utilitarian ageism. Both these forms of ageism were observed in an empirical study of social preferences in Australia. The study lends some support to the assumptions in the QALY approach that duration of benefits, and hence also age, should count in prioritising at the budget level in health care.

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.

Voluntary euthanasia and medically assisted suicide can be distinguished in terms of the causal roles performed by the doctor and the patient. In voluntary euthanasia, the doctor deliberately or intentionally ends the patient's life, at the patient's request; in assisted suicide, the patient deliberately or intentionally ends her life, with the purposeful assistance of her doctor. It is often assumed that a morally relevant and practically workable distinction can be drawn between cases of the intentional termination of life, on the one hand, and the provision of potentially life-shortening palliative care and the withdrawal and withholding of life-sustaining treatment, on the other. For many patients, death is no longer the natural event it once was. Rather, it is very often the result of a deliberate medical end-of-life decision. The Australian study demonstrates that large numbers of Australian doctors are intentionally ending the lives of patients.

It is widely believed that reproductive human cloning is morally wrong and should be prohibited because it infringes on human uniqueness, individuality, freedom and personal identity. The philosophical and ethical discussion has, however, shown that it is far more difficult than might initially be supposed to sustain arguments against cloning on these and related grounds. More recently, a potentially viable argument, initially put forward by Hans Jonas, has regained new prominence. The argument holds that cloning is wrong because it denies the clone an `open future', that is, the ability to freely shape her own personal identity, life plans, self-chosen goals, etc. After a critical exposition of the argument, I argue as follows: If one understands the Open Future Argument as an argument about the welfare of the cloned child, then it cannot show that cloning harms the child in a person-affecting sense of harming and benefiting. If, on the other hand, one understands the argument in a non-person-affecting sense, then some, but not all, reproductive cloning decisions can be shown to be wrong. The argument does not show, however, that cloning ought to be prohibited by law. While cloning, like other widely accepted reproductive decisions, will sometimes fail to minimize harm to `the child', such acts – to the extent that they do not constitute harm in a person-affecting sense – ought to be tolerated by proponents of the Open Future Argument. Attempts to prohibit reproductive choices on the basis that they are not optimal, will undermine the same set of values that the Open Future Argument seeks to uphold.

What should Japanese doctors do when asked by a patient for active voluntary euthanasia (VE), when the family wants aggressive treatment to continue? In this paper, we present the results of a questionnaire survey of 366 Japanese doctors, who were asked how they would act in a hypothetical situation of this kind, and how they would justify their decision, 23% of respondents said they would act on the patient’s wishes, and provided reasons for their view; 54% said they would not practice VE, either because they were opposed to VE as such, or because they believed that the wishes of the patient’s family should be respected. Analysis of these responses yielded the following results: Doctors willing to respect the patient’s wishes defended their decision by highlighting the significance of patient autonomy and the patient’s exclusive ownership of his or her life; doctors unwilling to act on the patient’s wishes fell into two broad categories — those who based their reasoning on the family’s objections, and those who provided other reasons for refusing VE. Respondents who said they would not comply with the patient’s wishes because of family objections provided the following kinds of rationale: doctors have serious responsibilities not only to the patient, but also to the patient’s family; the importance of the family-doctor relationship; fear of lawsuits for murder and related criminal offences; the need for agreement among all those affected by the decision, and the belief that the patient’s life is not his or her own, but the family’s. Respondents who gave non-family centred reasons for not complying with the patient’s wishes pointed to values such as the sanctity of life, or the importance of a natural death In the remainder of this paper, we discuss the implications of a family-centred approach to VE.

The philosophical debate over the moral difference between killing and letting die has obvious relevance for the contemporary public debate over voluntary euthanasia. Winston Nesbitt claims to have shown that killing someone is, other things being equal, always worse than allowing someone to die. But this conclusion is illegitimate. While Nesbitt is correct when he suggests that killing is sometimes worse than letting die, this is not always the case. In this article, I argue that there are occasions when it is better to kill than to let die.

The association of women with caring dispositions and thinking has become a persistent theme in recent feminist writing. There are a number of reasons for this. One reason is the impetus that has been provided by the empirical work of Carol Gilligan on women’s moral development. The fact that this association is not merely an ideologically or philosophically postulated one, but is argued for on empirical grounds, tends to add to its credibility. Another reason for the resilience of the association is the existence of an increasingly prominent theme in feminist thought and action that focuses on the importance of women’s difference from men, both as a fact and as a goal. Within this theme, there are various views on what the relevant differences are between women and men, and why the differences ought to be emphasized and properly respected. Women’s caring, as will be seen, turns out to have a firm presence in all of these views, and as a result, many women argue that caring should form the basis of a distinctive feminist ethic. On these views, women’s approaches to understanding moral situations, defining selfconceptions, choosing goals and roles, and guiding behaviour, should all be informed by and based upon dispositions of caring. However, if this idea of a feminist ethic of care is to be plausible, it will need to be reconciled with another strong theme in feminism, according to which in fundamental moral respects women ought not be considered or treated differently from men. We will examine the standing of a feminist ethic of care in the context of this tension between the difference theme and the sameness theme in feminism. The discussion begins by re-characterizing the justice and care debate in terms of impartialist and partialist ethical perspectives, and it then goes on to indicate the various ways in which women’s presumed disposition to caring and partialism finds prominence within the difference theme. The central focus of the discussion, however, will be the question of how to reconcile the conflict that exists between impartialist, justice-based moral thinking, and a partialist, caring approach to morality. The impetus for addressing this question arose from the results of an empirical study we conducted concerning gender-oriented differences in partialist and impartialist ethical reasoning. That study is summarized here, and a two-levels philosophical view of moral thinking is proposed to explain its results. This philosophical view not only

OBJECTIVES: To determine the relationship between ethical reasoning and gender and occupation among a group of male and female nurses and doctors. DESIGN: Partialist and impartialist forms of ethical reasoning were defined and singled out as being central to the difference between what is known as the "care" moral orientation (Gilligan) and the "justice" orientation (Kohlberg). A structured questionnaire based on four hypothetical moral dilemmas involving combinations of (health care) professional, non-professional, life-threatening and non-life-threatening situations, was piloted and then mailed to a randomly selected sample of doctors and nurses. SETTING: 400 doctors from Victoria, and 200 doctors and 400 nurses from New South Wales. RESULTS: 178 doctors and 122 nurses returned completed questionnaires. 115 doctors were male, 61 female; 50 nurses were male and 72 were female. It was hypothesised that there would be an association between feminine subjects and partialist reasoning and masculine subjects and impartialist reasoning. It was also hypothesised that nurses would adopt a partialist approach to reasoning and doctors an impartialist approach. No relationship between any of these variables was observed.

Objective: To estimate the proportion of medical end-of-life decisions in Australia, describe the characteristics of such decisions and compare these data with medical end-of-life decisions in the Netherlands, where euthanasia is openly practised. Design: Postal survey, conducted between May and July 1996, using a self-administered questionnaire based on the questionnaire used to determine medical end-of-life decisions in the Netherlands in 1995. Participants: A random sample of active medical practitioners from all Australian States and Territories selected from medical disciplines in which there were opportunities to be the attending doctor at non-acute patient deaths, and hence to make medical end-of-life decisions. Main outcome measure: Proportion of Australian deaths that involved a medical end-of-life decision, using ratio-to-size estimation based on the sampled doctors' responses to the questionnaire. The response rate was 64%. Results: The proportion of all Australian deaths that involved

This article presents an empirical study of approaches to ethical decision-making among nurses and doctors. It takes as its starting point the distinction between the perspectives of care and of justice in ethical thinking, and the view that nurses' thinking will be aligned with the former and doctors' with the latter. It goes on to argue that the differences in these approaches are best understood in terms of the distinction between partialist and impartialist modes of moral thinking. The study seeks to determine the distribution of these modes of thinking between nurses and doctors, and finds that there are no signif icant differences between them. A 'two-level' philosophical view of the nature of moral thinking is appealed to in order to explain the study findings.

Harris argues that if QALYs are used only 50% of the population will be eligible for survival, whereas if random methods of allocation are used 100% will be eligible. We argue that this involves an equivocation in the use of "eligible", and provides no support for the random method. There is no advantage in having a 100% chance of being "eligible" for survival behind a veil of ignorance if you still only have a 50% chance of survival once the veil is lifted. A 100% chance of a 50% chance is still only a 50% chance. We also argue that Harris provides no plausible way of dealing with the criticism that his random method of allocation may result in the squandering of resources.

What proportion of available healthcare funds should be allocated to hip replacement operations and what proportion to psychiatric care? What proportion should go to cardiac patients and what to newborns in intensive care? What proportion should go to preventative medicine and what to treating existing conditions? In general, how should limited healthcare resources (people, facilities, equipment, drugs…) be distributed If not all demands can be met?

Impartialism in ethics has been said to be the common ground shared by both Kantian and utilitarian approaches to ethics. Lawrence Blum describes this common ground as follows:Both views identify morality with a perspective of impartiality, impersonality, objectivity and universality. Both views imply the ‘ubiquity of impartiality” – that our commitments and projects derive their legitimacy only by reference to this impartial perspective.

Since 1989 there has been an ongoing controversy about the limits of public discussion of bioethical issues in the German-speaking world. While a number of scholars have been involved, Peter Singer and Helga Kuhse have been the principal targets of those seeking to limit bioethical debates. Those who have supported silencing discussion of certain issues have argued that such public discussion leads to a loss of freedom. In the article we argue that toleration is not based on subjectivism but rather on reason. Furthermore, the efforts to suppress debate are often based on a failure to understand our position. Such efforts at suppression also rest on an elitist view of society that must assume that the general public cannot debate such topics.

This article presents the results of a survey of the attitudes and practices of nurses in Victoria with regard to requests for active or passive help in dying from patients who were suffering from a terminal or incurable disease. Questionnaires were sent to 1942 nurses who had been selected at random, 943 nurses (49%) of whom returned completed questionnaires. The survey indicates that a clear majority of those who responded to the questionnaire support active voluntary euthanasia. Many nurses have collaborated with doctors in the provision of active voluntary euthanasia and a few have acted without consulting a doctor. Seventy-eight per cent of nurses thought the law should be changed to allow doctors to take active steps to bring about a patient's death under some circumstances; and 65% of nurses indicated that they would be willing to collaborate with doctors in the provision of active voluntary euthanasia if it were legal.

We examine the view that all human life is of equal worth or sanctity. We find that this view is a legacy of the Judeo- Christian tradition, and cannot be justified in non - religious terms. We therefore argue that it should be rejected, and that we should openly acknowledge that some Jives are of less worth than others. We then consider a common objection: that this will lead us down a slippery slope to Nazi- style atrocities. We give our reasons for finding this objection unpersuasive. We explain why no-one has any grounds for feeling threatened by our proposal. Finally we discuss who should make the decision involved in selecting whether a person should come into existence, and how that decision should be carried out.

The eugenic philosophies and policies of the 19th and early 20th century cast a dark shadow over contemporary genetics. In Europe, Great Britain and the United States, and in particular in Nazi Germany in the 1930’s and early 1940’s, eugenic practices were widespread. These practices included programs directed at the mass elimination of certain populations and groups, as well as the non-voluntary sterilization of the mentally disabled and criminally insane. In the United States, for example, the constitutionality of sterilization laws was upheld in the infamous 1927 US Supreme Court decision Buck v. Bell, when justice Oliver Wendell Holmes, jr. defended a compulsory sterilization order for Carrie Buck with the words: “Three generations of imbeciles are enough” (1927, pp. 1000–1002).

Perkin and Resnik advocate the use of muscle relaxants to prevent the "agony of agonal respiration" arguing that this is compatible with the principle of double effect. The proposed regime will kill patients as certainly as smothering them would. This may lead some people to reject the argument as an abuse of the principle of double effect. I take a different view. In the absence of an adequate theory of intention, the principle of double effect cannot distinguish between the intentional and merely foreseen termination of life, and cannot rule out end-of-life decisions that are often regarded as impermissible. What Perkin and Resnik are in effect saying is that there are times when physicians have good reasons to end a patient's life--deliberately and intentionally--for the patient's (and the family's) sake. Why not say so--instead of going through the agony of trying to match sanctity of life and patient-centred medical care?

Although euthanasia has been a pressing ethical and public issue, empirical data are lacking in Japan. We aimed to explore Japanese nurses’ attitudes to patients’ requests for euthanasia and to estimate the proportion of nurses who have taken active steps to hasten death. A postal survey was conducted between October and December 1999 among all nurse members of the Japanese Association of Palliative Medicine, using a self-administered questionnaire based on the one used in a previous survey with Australian nurses in 1991. The response rate was 68%. A total of 53% of the respondents had been asked by patients to hasten their death, but none had taken active steps to bring about death. Only 23% regarded voluntary active euthanasia as something ethically right and 14% would practice it if it were legal. A comparison with empirical data from the previous Australian study suggests a significantly more conservative attitude among Japanese nurses.

Following U.S. Justice Benjamin Cardozo’s declaration in 1914 that “Every human being of adult years and sound mind has a right to determine what shall be done with his own body” (Schloendorffv. Society of New York Hospital 1914), societies have, their institutions and laws, increasingly recognized that there is no absolute obligation to preserve and prolong life. Rather, there is no widespread agreement that competent and informed patients have a moral and legal right to refuse unwanted medical treatment, including life-sustaining treatment, for themselves. It is also widely assumed that this right can be extended into the future by way of advance directives, such as living wills and proxy directives. A living will allows a competent person to specify that she does not, when incompetent, wish to receive certain medical treatments, and a proxy directive allows her to appoint an agent or proxy who will be able to make treatment decisions for her should accident or illness render her incompetent.

A companion to bioethics , A companion to bioethics , کتابخانه مرکزی دانشگاه علوم پزشکی تهران

Modern nursing began with the revolutionary changes introduced by Florence Nightingale in the middle of the nineteenth century. At the time, virtually all nurses were women and all doctors were men. Like women in general, nurses were typically thought of as the helpmates of men — dependent functionaries who aided doctors in their work.

Giubilini and Minerva present a clear argument for the view that, other things being equal, reasons that justify abortion also hold for early infanticide.1 A reasoned argument deserves a reasoned response. Instead, many responses following the electronic publication of the article were mere outpourings of outrage and abuse to the authors and the editor of the Journal of Medical Ethics .2 The principal arguments put by Giubilini and Minerva date back some 40 years, when Michael Tooley presented a strong case for the moral equivalence of abortion and infanticide. According to Tooley, only ‘continuing selves’ are ‘persons’, and only persons can be ascribed a ‘right to life’. …

The Australian Medical Association's modification of the absolute rule requiring confidentiality in the doctor-patient relationship may be seen as a coming-of-age of the organisation. However, the change remains controversial: there are no guidelines as to when breaches of confidentiality are justified; and it is uncertain whether the new formulation will actually protect the public interest.

Harris levels two main criticisms against our original defence of QALYs (Quality Adjusted Life Years). First, he rejects the assumption implicit in the QALY approach that not all lives are of equal value. Second, he rejects our appeal to Rawls's veil of ignorance test in support of the QALY method. In the present article we defend QALYs against Harris's criticisms. We argue that some of the conclusions Harris draws from our view that resources should be allocated on the basis of potential improvements in quality of life and quantity of life are erroneous, and that others lack the moral implications Harris claims for them. On the other hand, we defend our claim that a rational egoist, behind a veil of ignorance, could consistently choose to allocate life-saving resources in accordance with the QALY method, despite Harris's claim that a rational egoist would allocate randomly if there is no better than a 50% chance of being the recipient.

In its 1980 Declaration on Euthanasia, the Roman Catholic Church reconfirmed its firm opposition to euthanasia of any kind: “… nothing and no one can in any way permit the killing of an innocent human being, whether a foetus or an embryo, an infant or an adult, an old person or one suffering from an incurable disease, or a person who is dying” ([20], p. 7). The Declaration captures what I want to call the “sanctity-of-life view”. This is the view that all innocent human lives are absolutely inviolable and equally valuable, and that the intentional termination of such lives is always morally wrong [11].

Economists have often treated the objective of health services as being the maximization of the QALYs gained, irrespective of how the gains are distributed. In a cross section of Australians such a policy of distributive neutrality received: (a) very little support when health benefits to young people compete with health benefits to the elderly; (b) only moderate support when those who can become a little better compete with those who can become much better; (c) only moderate support when smokers compete with non smokers; (d) some support when young children compete with newborns; and (e) wide spread support when parents of dependent children compete with people without children. Overall, the views of the study population were strongly egalitarian. A policy of health benefit maximization received very limited support when the consequence is a loss of equity and access to services for the elderly and for people with a limited potential for improving their health.