The battering of informed consent.

Autonomy has been hailed as the foremost principle of bioethics, and yet patients' decisions and research subjects' voluntary participation are being subjected to frequent restrictions. It has been argued that patient care is best served by a limited form of paternalism because the doctor is better qualified to take critical decisions than the patient, who is distracted by illness. The revival of paternalism is unwarranted on two grounds: firstly, because prejudging that the sick are not fully autonomous is a biased and unsubstantial view; secondly, because the technical knowledge of healthcare professionals does not include the ethical qualifications and prerogative to decide for others.Clinical research settings are even more prone to erode subjects' autonomy than clinical settings because of the tendency and temptation to resort to such practices as shading the truth when consent to participation is sought, or waiving consent altogether when research is done in emergency settings. Instead of supporting such dubious practices with unconvincing arguments, it would seem to be the task of bioethics to insist on reinforcing autonomy.

Who is my brother's keeper?

Clinical and research practices designed by developed countries are often implemented in host nations of the Third World. In recent years, a number of papers have presented a diversity of arguments to justify these practices which include the defence of research with placebos even though best proven treatments exist; the distribution of drugs unapproved in their country of origin; withholding of existing therapy in order to observe the natural course of infection and disease; redefinition of equipoise to a more bland version, and denial of post-trial benefits to research subjects. These practices have all been prohibited in developed, sponsoring countries, even though they invariably have pockets of poverty where conditions comparable to the Third World prevail. Furthermore, the latest update of the Declaration of Helsinki clearly decries double ethical standards in research protocols. Under these circumstances, it does not seem appropriate that First World scholars should propose and defend research and clinical practices with less stringent ethical standards than those mandatory in their own countries. Recent years have witnessed frequent reports of less stringent ethical standards being applied to both clinical and research medical practices, for the most part in the field of drug trials and drug marketing, initiated by developed countries in poorer nations. Still more unsettling, a number of articles have endorsed the policy of employing ethical norms in these host countries, which would be unacceptable to both the legislations and the moral standards of the sponsor nations. Also, these reformulations often contravene the Declaration of Helsinki or one of its updates. This paper is not so much concerned with the actual practices, which have been subjected to frequent scrutiny and publicly decried when gross misconduct occurred. Rather, my concern relates to the approval and support such practices have found in the literature on bioethics from authors who might be expected to use their energy and scholarship to explore and endorse the universalisability of ethics rather than to develop ad hoc arguments that would allow exceptions and variations from accepted moral standards. To this purpose, issue will be taken with arguments in three fields: medical and pharmaceutical practices, research strategies, and local application of research results.

Literary narrative in medical practice.

It is generally accepted that the practice of medicine could be improved by turning to the humanities in general, and to narrative and text interpretation in particular. Neverthless, there is hardly any agreement as to the nature of the clinical text, whether it be the patient's narrative that needs to be richly understood, or the patient as patient who must be both personally and clinically deciphered.We suggest that literary narratives depicting medical situations might serve as testimonials of the way medicine has or is being practised in a variety of social settings, and of the ways patients experience disease and medical care. By reading these texts, health care professionals could compare the situations and values involved in such narratives with current medical practices, thus perceiving how clinical encounters have changed and improved or, perhaps, continue to carry a burden of past flaws.

[Bioethical principles in public health: limitations and proposals]. / Principios bioéticos en salud pública: limitaciones y propuestas.

We propose to analyze the specificity of ethical problems in public health issues and to elucidate the applicability of principlism as a problem-solving strategy in this realm. Although well-established in clinical ethics, principlism is not an adequate model to be used in public health, since it is basically intended to serve as a moral guide in the physician-patient encounter. We discuss the possible adequacy of principles like "solidarity", "ontic responsibility" (as proposed by Jonas), and "caring or diaconal responsibility" as presented by Lévinas. Solidarity appears to be insufficiently specified, whereas the other two perspectives may be adapted to public health issues by bringing together Jonas' ontological and Lévinas' transcendental concerns to form a principle of protection that might better serve the purposes of such an ethics. This principle would help to identify more clearly the goals and agents involved in the implementation of public policies that are expected to be both morally correct and pragmatically effective.

In defence of medical ethics.

A number of recent publications by the philosopher David Seedhouse are discussed. Although medicine is an eminently ethical enterprise, the technical and ethical aspects of health care practices can be distinguished, therefore justifying the existence of medical ethics and its teaching as a specific part of every medical curriculum. The goal of teaching medical ethics is to make health care practitioners aware of the essential ethical aspects of their work. Furthermore, the contention that rational bioethics is a fruitless enterprise because it analyses non-rational social events seems neither theoretically tenable nor to be borne out by actual practice. Medical ethics in particular and bioethics in general, constitute a field of expertise that must make itself understandable and convincing to relevant audiences in health care.

Sanitary justice in scarcity.

Justice in health care and the allocation of scarce medical resources must be analyzed differently in affluent as compared to economically weaker societies. The protective functions of the state must be extended to cover basic needs for those too poor to meet them on their own. Medical needs are a high priority, since poor health hampers the ability to secure other basic needs. The state may operate as either a health care provider or supervisor, guaranteeing that citizens be treated fairly by nongovernmental institutions. Two-tiered systems with a vigorous private heath care sector are compatible with the explicit right to health care, provided the private tier operates without directly or indirectly draining public funds.

Theoretical aids in teaching medical ethics.

Medical ethics could be better understood if some basic theoretical aspects of practices in health care are analysed. By discussing the underlying ethical principles that govern medical practice, the student should also become familiar with the notion that medical ethics is much more than the external application of socially accepted moral standards. Professions in general and medicine in particular have internal values that command their moral virtuosity at the same time as their technical excellence. Three examples where clinical practice can be clearly shown to require an ethical analysis are given: medical praxiology illustrates the motives, means and aims of physicians and patients; clinical decision-making as a practical syllogism that reaches prescriptive conclusions based on medical knowledge and the patient's wishes/intentions. Finally, diagnostics as an ethical bayesian approach is discussed, where the patient informedly decides the benefits and risks of further testing.

[Changes in ethical attitudes during medical studies]. / Cambios de actitudes éticas a lo largo de los estudios de medicina.

The aim of this work was to explore the attitude changes towards ethico-medical issues in medical students as they went through medical school. A personal standardized questionnaire containing 14 closed and direct questions was applied to 27 freshmen, 38 interns and 14 post graduates. The most outstanding differences in ethical attitudes occurred between first year students and the older groups. The younger students adhered to ethical principles, valued justice towards patients and moral integrity in physicians. The older students and post graduates emphasized the professional role of physicians and preferred institutional ethical regulations over public control. They also considered more valuable therapeutic efficiency and paternal attitudes towards patients as well as social prestige and economical rewards. We conclude that there is a progressive erosion of humanistic principles along the medical studies, that are substituted by a model of professional competence, social recognition and internal ethical control.

Classical medicine v alternative medical practices.

Classical medicine operates in a climate of rational discourse, scientific knowledge accretion and the acceptance of ethical standards that regulate its activities. Criticism has centred on the excessive technological emphasis of modern medicine and on its social strategy aimed at defending exclusiveness and the privileges of professional status. Alternative therapeutic approaches have taken advantage of the eroded public image of medicine, offering treatments based on holistic philosophies that stress the non-rational, non-technical and non-scientific approach to the unwell, disregarding traditional diagnostic categories and concentrating on enhancing subjective comfort and well-being, but remaining oblivious to the organic substrate of disease. This leads to questionable ethics in terms of false hopes and lost opportunities for effective therapy.

Aspectos morfométricos, genéticos y sociológicos derivados de la atención oftalmológica de la Isla de Pascua / Morphometric, genetic and sociological aspects of opthalmological care in Easter Island

La primera parte de este estudio evalúa la morfometría de las papilas en 660 ojos de habitantes de Isla de Pascua, comparándola con las tensiones intraoculares encontradas. La gran mayoría de los pobladores pascuenses carecían de excavación papilar o presentaban una relación excavación/papila muy baja, en tanto que la población continental de la Isla tenía excavaciones substancialmente más grandes. Ello contrasta con las tensiones intraoculares medidas, cuya distribución y media eran iguales en los diferentes grupos étnicos de la Isla y tampoco diferían de otros estudios publicados. Esto confirma que el tamaño de la excavación papilar es un rasgo étnico, no necesariamente relacionado con la tensión intraocular o a la prevalencia de glaucoma. En la segunda parte, se analizan ciertos parámetros sociológicos de la atención oftalmológica en que se basó esta investigación, consignándose que los pascuenses consultaron en menor proporción relativa que los continentales y que el motivo de consulta difería en ambos grupos: en tanto los pascuenses acudían por patología orgánica, los continentales lo hacían por problemas de refracción. Junto con especular sobre las posibles explicaciones de estos diferentes comportamientos sociomédicos, los autores proponen tomar estos factores en consideración al planificar programas de atención médica

Atención oftalmológica en Isla de Pascua: desarrollo, aspectos epidemiológicos y étnicos / Ophthalmologic care in Easter Island: development, epidemiology and ethnic aspects

Entre los días 28 de octubre al 2 de noviembre de 1990, un equipo de oftalmólogos del Hospital San Juan de Dios de Santiago, Chile, atendió a 475 habitantes de Isla de Pascua. Los habitantes que presentaban una patología ocular fueron previamente seleccionados. Esta población seleccionada correspondió a un 20% del total de Isla de Pascua. Un 46% eran pascuenses puros; un 39% continentales; el resto mestizos. La frecuencia de discromatopsia en la población masculina pascuense fue de un 1,42%. Los pascuenses presentaban hendiduras palpebrales más anchas que las continentales, pero menores que las anglosajonas. En la población estudiada predominan las hipermetropias en los pascuenses y las miopías en los continentales

Against the magnanimous in medical ethics.

Supererogatory acts are considered by some to be part of medicine, whereas others accept supererogation to be a gratuitous virtue, to be extolled when present, but not to be demanded. The present paper sides with those contending that medicine is duty-bound to benefit patients and that supererogation/altruism must per definition remain outside and beyond any role-description of the profession. Medical ethics should be bound by rational ethics and steer away from separatist views which grant exclusive privileges but also create excessive demands, way beyond what physicians perform or are willing and able to offer.