Albert R. Jonsen

FETAL SURGERY FOR CONGENITAL HYDRONEPHROSIS

ALTHOUGH many fetal anatomic abnormalities can now be diagnosed by sonography, only a few will affect prenatal management.1 In the fetus with severe bilateral hydronephrosis secondary to urethral o...

Basic curricular goals in medical ethics.

Formal teaching of ethics in the medical school curriculum has increased greatly during the past 15 years. Yet, schools vary in how much attention they give the subject, and even those that do offe...

Clinical Decisions to Limit Treatment

A case of a patient with gastrointestinal hemorrhage raises the question of limiting medical treatment. We analyze four reasons to limit treatment: Treatment is futile, the patient refuses treatment, the costs of treatment seem excessive, and the quality of life is judged unacceptable. For cases in which treatment is to be limited, we offer practical suggestions for compassionate and appropriate terminal care.

Fetal treatment 1982.

Perinatal obstetricians, surgeons, ultrasonographers, pediatricians, bioethicists, and physiologists from centers active in fetal treatment (13 centers in 5 countries) gathered at Santa Ynez Valley...

Casuistry as methodology in clinical ethics

This essay focuses on how casuistry can become a useful technique of practical reasoning for the clinical ethicist or ethics consultant. Casuistry is defined, its relationship to rhetorical reasoning and its interpretation of cases, by employing three terms that, while they are not employed by the classical rhetoricians and casuists, conform, in a general way, to the features of their work. Those terms are (1) morphology, (2) taxonomy, (3) kinetics. The morphology of a case reveals the invariant structure of the particular case whatever its contingent features, and also the invariant forms of argument relevant to any case of the same sort: these invariant features can be called topics. Taxonomy situates the instant case in a series of similar cases, allowing the similarities and differences between an instant case and a paradigm case to dictate the moral judgment about the instant case. This judgment is based, not merely on application of an ethical theory or principle, but upon the way in which circumstances and maxims appear in the morphology of the case itself and in comparison with other cases. Kinetics is an understanding of the way in which one case imparts a kind of moral movement to other cases, that is, different and sometimes unprecedented circumstances may move certain marginal or exceptional cases to the level of paradigm cases. In conclusion, casuistry is the exercise of prudential or practical reasoning in recognition of the relationship between maxims, circumstances and topics, as well as the relationship of paradigms to analogous cases.

Watching the Doctor

IN some cultures, it is said, villagers cluster around a healer and a patient, eagerly listening to their conversation and observing their actions. In our culture, with its intensely private ways, ...

Casuistry and clinical ethics.

For the last century, moral philosophy has stressed theory for the analysis of moral argument and concepts. In the last decade, interest in the ethical issues of health care has stimulated attention to cases and particular instances. This has revealed the gap between ethical theory and practice. This article reviews the history and method of casuistry which for many centuries provided an approach to practical ethics. Its strengths and weaknesses are noted and its potential for contemporary use explored.

Ethics Consultation: The Least Dangerous Profession?

Whether ethics is too important to be left to the experts or so important that it must be is an age-old question. The emergence of clinical ethicists raises it again, as a question about professionalism. What role clinical ethicists should play in healthcare decision making – teacher, mediator, or consultant – is a question that has generated considerable debate but no consensus.

The Abuse of Futility

abstract: Two recent policy statements by major providers of critical care have rejected the concept and language of “medical futility,” on the ground that there is no universal consensus on a definition. They recommend using “potentially inappropriate” or “inappropriate” instead. We argue that their proposed terms are vague—even misleading—in the ICU setting, where serious life-and-death decisions are made. Whatever specific meaning the exclusive world of critical care might wish to give to the word inappropriate, in the lay world the term is so broad it trivializes the activity. We also point out that there is no universal consensus on the definition of death, the right to abortion, or the right to refuse blood products, yet medicine carries on. One advantage of the term “medical futility” is that it confirms unambiguously that human beings are mortal, and medicine’s powers are limited. It leads more naturally to integrating palliative and comfort care into critical care decision-making and encourages health providers to think more deeply about their role in the inevitable ending of their patients’ lives.

Ethical Decisions in the Care of a Patient Terminally III with Metastatic Cancer: An Ethics Case-Analysis from the Health Policy Program, University of California, San Francisco

Abstract A case of a patient with metastatic cancer raises the issues of patient refusal of treatment, euthanasia, and unintended side effects of therapy. For each management dilemma, there are rel...