The concept of futility. Patients do not have a right to demand medically useless treatment. Counterpoint.

Traditionally, applying the principle that physicians do not provide treatments when the interventions at their disposal do not produce medical benefits has been relatively straight-forward. However, with the growing importance of patient autonomy and informed consent in treatment decisions, ethicists must now balance this principle with the principle of patient self-determination. A patient's right to choose or refuse treatment is limited by the physician's right (and duty) to practice medicine responsibly. Bizarre or destructive choices made by a patient are not sacrosanct simply because the patient made them. In some cases, physicians may choose not to act on patient decisions that appear to be unreasonably destructive. Physicians also have a right to refuse to provide futile treatments (i.e., interventions that might be physiologically effective in some sense but cannot benefit a patient). Patients themselves have a right to provide input into what would constitute a "benefit" for them, but physicians should be able to decide when a particular treatment is futile based on their knowledge of the treatment's effects and its likely impact on a patient's quality of life. Ethical rules covering futility can be developed based on socially sanctioned standards of rationality and traditional physician-based values. Clarifying the concept of futility and establishing defensible ethical policies covering futility are important steps toward eliminating unhelpful, medically inappropriate practices.

Market economics and biomedical ethics.

Though biomedical ethics has only recently been recognized as a major new medical field, the connection between the practice of medical professionals and the ethics of medical practice dates back to the beginning of Western medicine. More recently, ethics has become more and more involved with economics.

Medical ethics and maternal-fetal conflicts.

As ethical issues are raised by more and more aspects of medical practice, medical ethics becomes an ever more complex and confusing enterprise, presenting yet another physician dilemma. This article offers guidelines for individual physicians and hospital ethics committees in dealing with medical ethics and maternal-fetal conflicts.

Anencephaly and the interruption of pregnancy: policy proposals for HECs.

This article is directed to hospital communities where absolute proscriptions exist against abortion. The assumption is that many will be Catholic institutions and therefore Catholic moral teachings are examined carefully. By addressing anti-abortion arguments in the context of anencephaly, I hope to show that within even the most conservative moral traditions, humane exceptions to absolute proscriptions against abortion can be justified. More specifically, the article is directed to HECs which either have unstated or ambiguous policies on abortion. It will attempt to show what a reasonable policy could look like and how it could be defended. For committee members not involved in policy questions about abortion, it may stimulate some ethical discussion.

PIP: Anencephaly, an always fatal neural tube defect, is posited to represent an instance where abortion is justified even within the most conservative anti-abortion traditions. Thus, Catholic hospital ethics committees are urged to adopt policies that provide pregnant women carrying an anencephalic fetus and hospital staff with freedom to act outside of traditional policies regarding the right to life of the fetus. The ethical justification for a relaxation of policy in this case rests on the premise that the purpose of pregnancy is to bring an emerging human to viability and independent existence. Because anencephalic fetuses have no capacity for human experience and the biological substrate essential for consciousness is absolutely lacking, the fetus must be regarded as a dying rather than emerging person. Removal of such a fatally flawed fetus thus should not be regarded as an act of murder, just as removal of an ectopic pregnancy or a cancerous pregnant uterus is not, and the moral imperative to accept the pregnancy should be waived. It is recommended that Catholic hospitals permit abortion of an anencephalic fetus if the medical diagnosis is firm and the pregnant woman makes an informed, free choice. Medical and nursing personnel who participate in such procedures should be provided with ethical education to avoid accusations of a violation of Catholicism's respect for human life. If a woman decides to carry an anencephalic fetus to term, this decision should be respected by staff.

Medical ethics in the 1990s. Emphasis on death-and-dying issues will continue but social concerns will command increased attention.

During the 1990s medical ethics will undergo changes. Individual clinical issues, especially those related to death and dying, will continue to create conflict and preoccupy hospital staffs. But professional ethicists will focus on social concerns more frequently than they have in the past. Following are some of the most crucial ethical issues and directions they are likely to take in this decade: Clinical practice and the law will move toward less demanding standards of proof regarding the withdrawal of treatment from patients who are no longer competent. Public policy will set more lenient standards for judging whether a person would refuse artificial nutrition and hydration if he or she were able. Unless sensible people strengthen the distinction between active and passive euthanasia, more physicians and legislatures will move toward physician-assisted suicide. Those proposing a higher-brain definition of death, as opposed to whole-brain definitions, will gain ground with the general public, but not with legislators. New transplantation technologies will increase medical options but create more problems with paying for the procedures. As techniques are perfected, ethical questions will focus more on financing than on the source of transplantable material. AIDS treatment priorities will clash with other medical demands (e.g., treatment for breast cancer), and concerns about protecting both providers and patients from contracting AIDS will move policy toward routine testing. Progress in public argument will be made on the abortion issue. Members of ethics committees will have to be trained to address financing issues. Some medical schools and residency programs will add courses on the concept of character and on character development to their ethics programs.(ABSTRACT TRUNCATED AT 250 WORDS)

Karl A. Menninger: psychiatrist and moralist.

Karl Augustus Menninger, whom the American Psychiatric Association declared "America's greatest living psychiatrist," died July 18, 1990, in Topeka, KS. He had lived there his entire life. In 1993 he would have been 100 years old. The name "Menninger" has become synonymous with psychiatry, principally through the work of this one man. In 1925, with his father and his brother William, he established the Menninger Foundation, a world-famous center for research, education, and treatment of mental illness. A leader in psychiatry for more than 70 years, Menninger wrote more than a dozen books and hundreds of articles. He gave thousands of lectures and directly helped thousands of psychiatric patients in addition to the hundreds of thousands of people he touched through his writings.

National survey of ethical issues presented to drug information centers.

Whether and how drug information centers respond to calls from the public that involve ethical issues was studied. A survey describing six ethical dilemmas typical of those presented by calls from the public was mailed to pharmacists in 154 drug information centers to see how the questions would be handled. Centers that had written policies governing responses to questions with ethical implications were asked to submit those policies. One hundred twenty-six centers (82%) responded to the survey; of these, 81 (64.3%) answered questions from the public. There were no significant differences in characteristics between centers that did and did not respond to public calls. The case analyses, completed only by pharmacists in centers that responded to public calls, covered such issues as invasion of privacy, social responsibility, personal liability, and interference with the patient-physician relationship. Respondents exercised a wide degree of discretion in determining if they would answer a question; for example, while only 4% would not answer a question concerning the efficacy of a weight-loss diet patch, 77% reported they would not respond to a caller asking for information on drugs that could interfere with the results of a polygraph test. Although respondents often cited institutional policy as the reason for failing to respond to a question, none submitted a copy of such a policy. The pharmacists' responses indicated a high degree of moral and social sensitivity; nonetheless, written policies should be developed to assist drug information center staff members in handling questions that have ethical implications.

[Methods of clinical ethics]. / Métodos de ética clínica.

Medical ethics decisions always entail a certain amount of difficulty. Clinical alternatives make the adoption of well-founded decisions quite difficult. Each case is different and does not lend itself to a predetermined decision. If a satisfactory method is used to make moral evaluations, serious mistakes can almost always be avoided and defensible decisions made. Medical ethics is many things, but in essence it is necessarily a strategy or method. True professional medical ethics requires a method that leads to moral discernment as well as uniformly appropriate decisions. One of the most important functions of a method is to keep standards of evaluation linked to facts. Good methods prevent medical ethics from falling into the trap of false generalization and keep it rooted in real-life situations.