ABSTRACT
The idea of establishing a market for organs is now the subject of unusual controversy. Proponents emphasize the concept of autonomy; opponents invoke fairness and justice. The controversy, however, has given sparse attention to what it would mean to society and medicine to establish a market in organs and to the intended and unintended consequences of such a practice. This article addresses these issues by exploring the tensions between 'extrinsic' and 'intrinsic' incentives, suggesting that donation might well decline were financial incentives introduced. It also contends that social relationship and social welfare policy would be transformed in negative ways and that a regulated market in organs would be extraordinarily difficult to achieve. Finally, it argues that organ sale would have a highly detrimental affect on medicine as a profession.
Subject(s)
Tissue and Organ Procurement/economics , Tissue and Organ Procurement/ethics , Humans , Kidney TransplantationABSTRACT
This essay explores the evolution of the tension between the principles of autonomy and beneficence in American health care over the past several decades. In retrospect it is clear that the social movements of the 1960s and 70s set the tone and the goals for the emergence of a new emphasis on patient autonomy. Indeed, the impact of civil liberties-minded lawyers on the promotion of a commitment to autonomy is far more vital than the term "bioethics" commonly suggests. Tracing the impact of this principle on clinical encounters over the past 25 years makes apparent that consumers have extended their influence over a wide range of treatment decisions. This influence is now being reinforced by an extraordinary information revolution, which includes the computer, the web, the dot.coms, the search engines, and such novel practices as Direct-to-Consumer advertising by pharmaceutical companies. The impact of these developments may be seen in such diverse issues as physician-assisted suicide and the failure of national health insurance initiatives.
Subject(s)
Patient Participation/trends , Patient Rights/trends , Personal Autonomy , Physician-Patient Relations , Advertising/trends , Beneficence , Drug Industry/trends , Humans , Informed Consent , Retrospective Studies , Social Change , Suicide, Assisted , United StatesABSTRACT
Little is known about the efficacy and safety of substances that are being promoted to consumers as "anti-aging" therapies. Hormones such as DHEA, human growth hormone, and testosterone tend to decline with aging, but the therapeutic value of replacing them to "normal" physiologic levels has not been substantiated by controlled clinical trials. The best source of antioxidants is a balanced diet, although older patients may benefit from vitamin E supplementation. Providing anti-aging medicine in the primary care setting means practicing good medicine. It means talking to patients who request these therapies and understanding why they want them and how much risk they're willing to take.
Subject(s)
Aging/drug effects , Antioxidants/pharmacology , Hormone Replacement Therapy , Antioxidants/adverse effects , Bone Density/drug effects , Bone Density/physiology , Calcium/pharmacology , Diet Therapy , Drug Approval , Hormone Replacement Therapy/adverse effects , Humans , Risk Assessment , Vitamins/adverse effects , Vitamins/pharmacologySubject(s)
Conflict of Interest , Physician's Role , Professional Practice/standards , Disclosure , Drug Industry , Ethics, Medical , Gift Giving , Humans , Legislation, Medical , Lobbying , Managed Care Programs/organization & administration , Managed Care Programs/standards , Patient Advocacy , Peer Review, Health Care , Physician Impairment , Professional Competence , Societies, Medical , United States , WhistleblowingSubject(s)
Control Groups , Developing Countries , Ethics, Research , HIV Infections , Human Experimentation , Research Design , AIDS Vaccines , Female , Helsinki Declaration , Humans , Infant, Newborn , Infectious Disease Transmission, Vertical , Informed Consent , Internationality , Male , Placebos , Pregnancy , Research Support as Topic , United States , Vulnerable Populations , ZidovudineABSTRACT
Over the past two decades, institutional review boards (IRBs) have transformed the conduct of clinical research, in the process protecting human subjects and setting an admirable standard for monitoring the ethics of science. Nevertheless, the very proliferation of these committees, in addition to changing the character and sponsorship of new research, suggests that a ¿one size fits all¿ approach to the governance of human experimentation may have outlived its usefulness. It may be time to remove the ¿I¿ from the IRB and create a system with greater national oversight. Whether such a change can be accomplished within the current political climate is debatable. But the need for such a shift is becoming increasingly apparent.
Subject(s)
Advisory Committees , Clinical Trials as Topic , Ethics Committees, Research , Ethics, Medical , Federal Government , Government Regulation , Human Experimentation , Professional Staff Committees/organization & administration , Committee Membership , Ethical Review , History, 20th Century , Human Experimentation/history , Humans , Personal Autonomy , Politics , Research , Social Justice , United StatesSubject(s)
Acquired Immunodeficiency Syndrome/epidemiology , Acquired Immunodeficiency Syndrome/history , Hospitals, Special/history , Mandatory Programs , Public Health Administration/history , Tuberculosis/epidemiology , Tuberculosis/history , Acquired Immunodeficiency Syndrome/therapy , History, 20th Century , Hospitals, Special/organization & administration , Humans , New York City/epidemiology , Tuberculosis/therapyABSTRACT
To understand fully the persistent failure of the United States to enact national health insurance requires an appreciation not only of the role of government and the dynamics of politics but of underlying social realities. One consideration, which dates back to the Great Depression, is the absence of the middle class from a coalition in favor of such a policy. This absence reflects both the constricted vision of the middle class and the spirited campaigns of groups like Blue Cross to make certain that middle-class needs were met in order to reduce pressure for government intervention. Another critical social feature is the special entrepreneurial character of the American medical profession. Physicians saw themselves as small businessmen and, as such, shared and promoted a suspicion of governmental intervention. All the while, Americans justified the absence of a national program in terms of the ethos of voluntarism, which had a sufficient base in reality for the posture to be maintained without great embarrassment. In fact, the rhetoric that surrounded the enactment of Medicare reinforced these views, making it appear that, the elderly aside, all was well with the provision of medical services in the country. Even as national health insurance assumes a new prominence on the political agenda, it remains unclear whether these several considerations will allow for the enactment of sweeping changes.
Subject(s)
Delivery of Health Care/history , Health Policy/history , Social Welfare/history , Delivery of Health Care/organization & administration , Forecasting , Health Policy/legislation & jurisprudence , History, 20th Century , Medicare/history , Physician's Role , Social Class , United States , VolunteersABSTRACT
New external pressures on hospitals are transferring power and authority from doctors to administrators and directors.
Subject(s)
Governing Board/organization & administration , Hospital Administration/history , Interprofessional Relations , Medical Staff, Hospital/organization & administration , Decision Making, Organizational , History, 19th Century , History, 20th Century , Hospital Administration/trends , Organizational Innovation , Physician's Role , Power, Psychological , Professional Autonomy , United StatesABSTRACT
From the treatment IND to drug importation, to the parallel track and beyond, AIDS advocates have largely succeeded in doing what earlier FDA critics were unable to do: take more decisions out of the hands of government and the research establishment and cede them to patients and their physicians. The profound ethical and clinical implications are discussed.