The origins of bioethics: advances in resuscitations techniques.

During the last years there has been an increasing interest in meta-bioethical issues. This turn in the research focus is regarded as a sign of the maturation of bioethics as a distinct area of an academic inquiry. The role of historic-philosophical reflection is often emphasized. It should be noted that there is a rather common agreement that the future of bioethics lies in the critical reflection on its past, in particular, on the very origins of this discipline. Sharing Caplan's opinion, advances in medicine technologies, especially the introduction of respirators and artificial heart machines, is considered as one of the main issues that started bioethics. Using methods of historical as well as meta-ethical research, this article aims at describing the role of advances in resuscitation techniques in the emergence of bioethics and at exploring how bioethical reflection has been shaped by technological developments. A brief historical analysis permits to say that there is a close bond between the emergence of bioethics and the introduction of sophisticated resuscitation technologies into medical practice. The meta-ethical reflection reveals that advances in resuscitation techniques not only initiated bioethics in the second half of the 20(th) century but influenced its evolution by (i) posing a question of justice in health care, (ii) altering commonly accepted ontological notions of human corporeality, and (iii) reconsidering the very purpose of medicine.

Ethics in studies on children and environmental health.

Children, because of age-related reasons, are a vulnerable population, and protecting their health is a social, scientific and emotional priority. The increased susceptibility of children and fetuses to environmental (including genotoxic) agents has been widely discussed by the scientific community. Children may experience different levels of chemical exposure than adults, and their sensitivity to chemical toxicities may be increased or decreased in comparison with adults. Such considerations also apply to unborn (fetal exposure) and newborn (neonatal exposure) children. Therefore, research on children is necessary in both clinical and environmental fields, to provide age-specific relevant data regarding the efficacy and safety of medical treatments, and regarding the assessment of risk from unintended environmental exposure. In this context, the stakeholders are many, including children and their parents, physicians and public health researchers, and the society as a whole, with its ethical, regulatory, administrative and political components. The important ethical issues are information of participants and consent to participate. Follow-up and protection of data (samples and information derived from samples) should be discussed in the context of biobanks, where children obtain individual rights when they become adults. It is important to realise that there are highly variable practices within European countries, which may have, in the past, led to differences in practical aspects of research in children. A number of recommendations are provided for research with children and environmental health. Environmental research with children should be scientifically justified, with sound research questions and valid study protocols of sufficient statistical power, ensuring the autonomy of the child and his/her family at the time of the study and later in life, if data and samples are used for follow-up studies. When children are enrolled, we recommend a consent dyad, including (1) parental (or legal guardian) informed consent and (2) the child's assent and/or informed consent from older minors. For evaluation of the studies including children, a paediatrician should always be involved in the research ethics committee.

Advance directives and the concept of competence: are they a moral barrier to resuscitation?

The ethical reflection on the principle of respect for autonomy has evolved from protecting the patients' right to direct health care decisions affecting them, to describing essential conditions necessary to recognize the patients' consent as being really informed. Some specific problems arise with patients who are not autonomous or whose autonomy is doubtful at the time of undertaking medical treatments. The advance directives are seen as a means which permits to respect the patient's autonomy even in such difficult situations. Such directives are understood as the declarations made by patients in which they express the will concerning treatment preferences, in particular, resuscitation recommendations, in case of their potential future lack of ability to act autonomously. This paper attempts to answer to the question of whether the advance directives fulfill (and if so, on what basis) the standards established by the concept of competence.

'Do not resuscitate order' in neonatology: authority rules.

Ethical dilemmas in medicine should be resolved in light of four essential principles. To specify and guide concrete actions, it is necessary to 'supplement' these principles by certain other (substantive, authority and procedural) rules. The purpose of this paper is to establish and justify the authority rules regarding the order not to resuscitate newborns. The authority rules are intended to indicate who should decide, but they do not determine what should be chosen. Decision regarding newborn's treatment/letting die depends on medical and quality-of-life judgments. Parents, doctors, and society are considered to possess decisional authority in the matter. However, who in a given case should decide ought to be inferred from the reasoning which assumes, as its premises, the medical and quality-of-life judgments. The 'logical' syntax of this reasoning is presented in this paper.

The influence of religious beliefs on health care: between medical futility and refusal of treatment.

The problem of respecting the patients' religious-based decisions seems to play increasingly important role in medical practice. Most probably it happens because: (i) bioethical standards accentuate the principle of the respect for autonomy (the departure form medical paternalism) and (ii) the contacts between people belonging to different religious traditions are becoming more and more frequent (the process of globalization). Toleration, in particular toleration of patients' religious convictions, needs to be considered as a vital issue for the pluralistic societies. A four-principle approach to medical ethics is assumed as a theoretical base for this study. The main methodological steps could be described as: (i) identification of a ,considered judgment' (proper to the problem in concern), (ii) its specification, and (iii) balancing/ overriding. According to the internationally accepted proclamations of human rights, the positive obligation to tolerate religious beliefs is indicated as the principle which should govern the process of dealing with the patients' religiously motivated decisions. The special status of patients' religious-based decisions as well as the 'obliging force' of them is considered. The article concludes with guidelines on how to help doctors resolve moral dilemma related to tolerance of patients' religious-based decisions.

Defining health/illness: societal and/or clinical medicine?

Medicine is becoming more and more 'technologically' powerful. To protect patients, doctors and societies from misuse of this power it is necessary, as before, to indicate, as clearly as possible, the very purposes of medicine. Providing precise definitions of the fundamental concepts of medicine such as 'health'/'illness' ('disease', 'sickness') becomes in this context a crucial issue. The literature review was commissioned to identify key approaches to defining 'health'/,illness'. The collected definitions were classified according to the criteria: the positive/negative character of the definition, the naturalist/normativist approach; analytic/synthetic (constructive or precising) type of definition, the goal-oriented/ideal-oriented definition. The Venn's diagrams were used to visualize the relationship existing between studied terms. Using the concept of a triad of disease-illness-sickness, the positive definition of ailment was introduced. It was indicated that the paradigmatic role in medicine plays the term 'illness' rather than 'disease'. The World Health Organization's definition of health was critically evaluated and instead of it, a harmonistic definition was proposed. In conclusion, the wording of a harmonistic definition presented in the article should be considered as a starting point for further considerations. Several directions of such considerations were proposed.

Language and thinking: analysis of breathing-related phraseology.

In the contemporary bioethics, patient's autonomy is often recognized as the most important issue. This autonomy is interpreted as the right to self-determination regarding all medical-related decisions. An essential condition of autonomous decisions is the adequate knowledge of the issues involved. The "informed consent" has become a gold standard of bioethics. All this leads to focusing on the problems related to communication, and, in consequence, on the language as a fundamental tool of communication. The aim of the article was to reveal the meaning of "breath(e)/breathing" and in that way to contribute to a better communication between doctors and patients. An analysis was performed using a method of non-analytical philosophy of language. English, Italian, and Polish were chosen as subjects of this study. The results clearly show the multiplicity and variety of meanings that assume breathing-related linguistic expressions. All of them are classified in four main groups. In conclusion, the author submits that an improvement in the understanding of different meanings of words used in the doctor-patient relationship can contribute to maintaining ethical standards in medical practice.