John C. Fletcher

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...

Participation in biomedical research : the consent process as viewed by children, adolescents, young adults, and physicians

We examined the capacity of children, adolescents, and young adults to assent and consent to participation in biomedical research, and what physician-investigators believe is important for patients in these age groups to know about such participation. The sample included 44 male and female subjects, ranging in age from 7 to 20 years, who were hospitalized to treat either pediatric cancer or obesity. The participants completed a structured interview that assessed knowledge of research participation using the elements outlined in the federal guidelines for informed consent. The study subjects were most knowledgeable about those elements of consent that assessed concrete information (e.g., freedom to ask questions, time elements involved, and the benefits of participation). They were less knowledgeable about those elements of informed consent that assessed abstract information (e.g., scientific vs therapeutic purpose of the study, and alternative treatments). Chronologic age was not related to knowledge of the elements of informed consent. The strategies that the study subjects used to reason about participation in research appeared to parallel their reasoning about other physical phenomena.

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...

Maternal Bonding in Early Fetal Ultrasound Examinations

WE have recently seen two cases in which women in the late first or early second trimester of pregnancy reported feelings and thoughts clearly indicating a bond of loyalty toward the fetus that we ...

Ethics and human genetics: a cross-cultural perspective.

This final chapter will discuss these questions: 1) As viewed cross-culturally, what are the major ethical problems in the practice of human genetics today? What are the major social-ethical and policy issues presented to societies and their leaders today and in the near future? 2) What will happen if ethically adequate, unified, and teachable approaches to these issues are not developed? 3) How can the results of this study help to develop such approaches? 4) Is there a viable cross-cultural perspective in ethics for evaluating different cultural and personal approaches to ethical problems in human genetics? Is there a constructive “middle ground” between ethical relativism and ethical absolutism? 5) If so, what evaluations can we make from this perspective about the prevailing approaches to difficult ethical problems in medical genetics today and in the near future? 6) What priority should human genetics and genetic services have in society’s overall medical expenditures? What are geneticists’ responsibilities towards formulating public policies affecting human genetics and reproductive choices? 7) What steps can medical geneticists, policy makers, and public and parent groups take, nationally and internationally, to study social-ethical issues in this field?

The Care of the Terminally Ill: Morality and Economics

Are current expenditures on dying patients disproportionate, unreasonable, or unjust? Although a review of empirical data reveals that care for the terminally ill is very costly, it is not appropriate to conclude that such expenditures represent a morally troubling misallocation of societal resources. Moreover, though efforts to reduce the costs of caring for the dying are not unreasonable, they must be undertaken with great caution. At present, such efforts should concentrate on three basic goals: development of better criteria for admission to intensive- and critical-care units; promotion of patient and family autonomy with regard to decisions to stop or refuse certain kinds of treatment; and promotion of alternative forms of institutional care, such as hospice care. The most difficult moral problems will arise when patients and their physicians seek access to therapies judged only marginally useful. There may be conflict between administrators with broad institutional responsibilities and clinicians committed to particular patients.

Informed consent in children and adolescents: Age, maturation and psychological state

PURPOSE The purpose of this investigation was to examine the relationship of understanding of research participation to anxiety, control, and stage of cognitive development. METHODS Participants included 44 boys and girls ages 7 to 20 years. All were inpatients for the first time in pediatric units of a research hospital. Twenty participants were admitted for experimental treatment of pediatric cancers and 24 were admitted for a 3-week treatment of extreme obesity. An interview was conducted to assess 12 elements of knowledge of research participation of a medical protocol. The interview was coded for: 1) knowledge of research participation score, 2) weighted knowledge of participation in research score (based on physician ratings of what was most-to-least important for children and adolescents to know), and 3) global control (perceived control over life, illness and treatment). A measure of anxiety and one Piagetian task to measure stage of cognitive development also were administered. RESULTS Pearson correlations, significant at p < or = .05, were as follows: knowledge of participation in research and global control, (r = .40) and weighted knowledge of participation in research score and global control (r = .38). Hierarchical regression showed that the best predictors of knowledge of research participation or the weighted knowledge of research participation score was global control alone or an interaction of global control with anxiety. CONCLUSIONS Emotional factors were more frequently related to understanding of research participation than age or cognitive development. Providing medical environments that decrease anxiety and increase control may enhance childrens and adolescents understanding of the research process.

Ethical and social issues in prenatal sex selection: a survey of geneticists in 37 nations.

In a recent 37-nation survey of 2903 geneticists and genetic counselors, 29% would perform prenatal diagnosis (PND) for a couple with four girls who want a boy and would abort a female fetus. An additional 20% would offer a referral. The percentage who would perform PND in the United States (34%) was exceeded only by Israel (68%), Cuba (62%), Peru (39%), and Mexico (38%). In all, 47% had had requests for sex selection. There appears to be a trend toward honoring such requests since a similar survey in 1985. This paper discusses reasons for this trend and the ethical dilemmas of refusing patient requests in societies where individual autonomy is stressed.

Fetal reduction from twins to a singleton: a reasonable consideration?

OBJECTIVE: In the past, our group took the position that we would not provide multifetal pregnancy reduction to a singleton regardless of starting number except for serious maternal medical indications or as a selective termination for diagnosed fetal anomalies. With evidence of increased safety and more women (many aged 40 years or more) asking for counseling about reduction to a singleton, we reviewed our prior reasoning. METHODS: We compared outcomes of 52 first-trimester twin-to-singleton for multifetal pregnancy reduction cases performed by a single operator to twin and singleton data from recent national register studies. RESULTS: Twin-to-singleton reductions represent less than 3% of all cases. Forty of 52 patients were aged 35 years or more, 19 were aged more than 40 years, and 2 were aged more than 50 years (age range 32–54 years). Since 1999, 23 of 28 had chorionic villus sampling before multifetal pregnancy reduction. Fifty-one of 52 reached viability with mean gestational age at delivery of 37.2 weeks. One of 52 patients miscarried (1.9%). Compared with multiple sources of data for twins, the loss rate is lower in twins reduced to a singleton. CONCLUSION: Until recently, multifetal pregnancy reductions to a singleton were rare. Physicians were concerned about the unknown risks of multifetal pregnancy reduction in this situation. They also had moral doubts about the justification to go “below twins.” However, physicians know that spontaneous twin pregnancy losses average 8–10%. Also, with experience, multifetal pregnancy reduction has become very safe in our hands. Our data suggest that the likelihood of taking home a baby is higher after reduction than remaining with twins. We propose that twin-to-singleton reductions might be considered with appropriate constraints and safeguards. LEVEL OF EVIDENCE: III

Fatal Knowledge? Prenatal Diagnosis and Sex Selection

Moral and social arguments weigh heavily against performing medical procedures solely for purposes of sex selection. The medical profession has a responsibility to abandon its posture of ethical neutrality and take a firm stand now against sex selection.