Donna Dickenson

Ethical Issues in Limb Transplants

On one view, limb transplants cross technological frontiers but not ethical ones; the only issues to be resolved concern professional competence, under the assumption of patient autonomy. Given that the benefits of limb transplant do not outweigh the risks, however, the autonomy and rationality of the patient are not necessarily self-evident. In addition to questions of resource allocation and informed consent, limb, and particularly hand, allograft also raises important issues of personal identity and bodily integrity. We present two linked schemas for exploring ethical issues in limb transplants. The first, relying on conventional concepts in biomedical ethics, asks whether the procedure is research or therapy, whether the costs outweigh the benefits, and whether it should be up to the patient to decide. The second introduces more speculative and theoretically challenging questions, including bodily integrity, the argument from unnaturalness, and the function of the hand in expressing personal identity and intimacy. We conclude that limb transplants are not ruled out a priori, unlike some procedures that are prima facie wrong to perform, such as amputation of healthy limbs to relieve body dysmorphic disorders. However, their legitimacy is not proven by appeals to the interests of scientific research, cost-benefit, or patient autonomy.

Evidence-based medicine and quality of care.

In this paper we set out to examine thearguments for and against the claim thatEvidence-Based Medicine (EBM) will improve thequality of care. In particular, we examine thefollowing issues:1. Are there hidden ethical assumptions in the methodology of EBM?2. Is there a tension between the duty of care and EBM?3. How can patient preferences be incorporated into quality guidelines and effectiveness studies?4. Is there a tension between the quality of a particular intervention and overall quality of care?5. Are certain branches of medicine and patient groups innately or prima facie disadvantaged by a shift to EBM?In addition we consider a case study in theethics of EBM, on a clinical trial concerningthe collection of umbilical cord blood inutero and ex utero, during or afterlabour in childbirth.

Can medical criteria settle priority-setting debates? The need for ethical analysis.

Medical criteria rooted in evidence-based medicine are often seen as a value-neutral ‘trump card’ which puts paid to any further debate about setting priorities for treatment. On this argument, doctors should stop providing treatment at the point when it becomes medically futile, and that is also the threshold at which the health purchaser should stop purchasing. This paper offers three kinds of ethical criteria as a counterweight to analysis based solely on medical criteria. The first set of arguments concerns futility, probability and utility; the second, justice and fairness; the third, consent and competence. The argument is illustrated by two recent case studies about futility and priority-setting: the US example of ‘Baby Ryan’ and the UK case of ‘Child B’.

Abortion, Relationship, and Property in Labor: A Clinical Case Study

This paper explores an anonymized case study of diagnosed fetal abnormality in the third trimester in terms of several sorts of relationships that overlap rather than conflict with the notion of the pregnant womans property in the body. It argues that the moral significance of birth is not so much significant for the fetus/infant as compared to the pregnant woman/mother. This paper further argues that the pregnant womans property right in her labor is typically ignored in the abortion debate. Four property relations are considered in the discussion: the pregnant womans right to exclude others from deciding on the abortion; her right to transfer life to the fetus; her right to choose to abjure her own right not to give birth in favor of another beneficiary; and the doctors right or duty to alienate custody of the fetus from the pregnant woman.