Roberta Springer Loewy

Bioethics at the Crossroad

Bioethics and its offspring Health-care Ethics have a variety ofuses and obligations among which and perhaps most importantly istheir social obligation. This paper raises questions as toBioethics fulfilling the necessary criteria for a profession,suggests that it can serve as a link between individual andcommunal problems, discusses the task of health-care ethics as well as ways of teaching it, lists some of the obligationsof health-care ethics professionals and discusses the dangers to and failings of these health-care professionals today. Itconcludes that we are at a crossroads in which we must choosebetween our own personal security and comfort and fulfilling our social role.

Use and abuse of bioethics: integrity and professional standing.

This paper sets out to examine the integrity and professional standing of “Bioethics.” It argues that professions have certain responsibilities that start with setting criteria for and credentialing those that have met the criteria and goes on to ultimately have social responsibilities to the community. As it now stands we claim that Bioethics—while it certainly has achieved some progress in the way medicine has developed—has failed to become a profession and has to a large extent failed in its social responsibility. We feel that Bioethics has to define itself, set criteria for membership in the profession, police itself and—above all—meet its social responsibility to become a profession meriting that name.

Lebensunwertes Leben and the Obligation to Die: Does the Obligation to Die Rest on a Misunderstanding of Community?

In this paper the authors address the recent argument that we have an obligation to seek or actively bring about our own death when we burden others too greatly. Some of the problems with this argument and some of the practical conseqeuences of adopting such a point of view are discussed in this paper. We argue that the argument rests on an individualistic approach which sees the family being burdened as standing alone instead of seeing it as embedded in a burden-sharing community.

Written advance directives: Theuth's blessing ... or ... curse?

SummaryAdvance directives are discussed from a philosophical standpoint and with reference to their relationship to informed consent. The necessity of an advance directive being truly informed is stressed. The author suggests that the validity of these instruments is made quite difficult when the particular context in which they find themselves is one which neither patient nor physician anticipated.

Hastening Death by Selective Disclosure of Treatment Options—Beneficence or "Euthanasia by Deception"?

In this paper I make a radical claim regarding selective non-disclosure of treatment options that have some hope of prolonging a patients life. I suggest that selective non-disclosure under such circumstances is tantamount to what might be called “euthanasia by deception.” I offer a case to test the validity of my claim and to demonstrate how the failure to offer or, at least, to discuss renal dialysis in this case (and, by inference, any other form of treatment which has some hope of prolonging a patients life) qualifies as paternalism in its most egregious form. I discuss the actions of the health care team and try to find some plausible reasons why they acted as they did. I conclude that there must be greater emphasis placed on teaching clinicians how better to incorporate frank, open and on-going discussion about the central elements of the therapeutic relationship with patients long before they lose decisional capacity.

Honouring the age-old commitment to "the patient's good": the promise--and peril--of hospice.

In this article, the rise of hospice in the United States is examined and some of its important strengths and weaknesses are described. It is suggested that, despite the tendency to believe otherwise, hospice is not immune to a kind of alienation between patients and clinicians based on the absorption of doctors with biomedical conditions and their possible technological remedies, thus overlooking or ignoring the patient’s good. To protect the age-old fiduciary or “trust” relationship between patients and clinicians requires a re-adjustment of current attitudes and practices – not just in the current cure-oriented health care of conventional medicine, but in the palliation-oriented health care of hospice as well. That is, it requires the development of attitudes and practices that foster a democratic, multidisciplinary process of shared decision-making and the adoption of a genuinely bio/psycho/social understanding and articulation of “the patient’s good” – irrespective of where along the continuum of care patients and clinicians find themselves. In diesem Artikel wird die Entwicklung der Hospizbewegung in den USA untersucht und einige bedeutende Stärken und Schwächen beschrieben. Es wird argumentiert, dass – trotz anderwärtiger Vermutungen – auch die Hospizbewegung nicht immun gegen eine Verfremdung zwischen Arzt und Patient ist, die auf einer Überbetonung der biologischen Probleme sowie deren technologischer Lösungen beruht und das individuelle Ziel des Patienten (sein eigentliches Anliegen) übersieht. Um die altehrwürdige Tradition der Fürsorge und Treuhänderschaft zwischen Arzt und Patient aufrecht zu erhalten, bedarf es einer Änderung der üblichen Einstellungen und Praktiken, um einen demokratischen, interdisziplinären, gemeinsamen Entscheidungsprozeß zu ermöglichen. Ziel ist es, ein bio-psycho-soziales Verständnis der eigentlichen Patientenbedürfnisse (the patient’s good) während des gesamten Kontinuum der Arzt-Patient Beziehung zu finden.SummaryIn this article, the rise of hospice in the United States is examined and some of its important strengths and weaknesses are described. It is suggested that, despite the tendency to believe otherwise, hospice is not immune to a kind of alienation between patients and clinicians based on the absorption of doctors with biomedical conditions and their possible technological remedies, thus overlooking or ignoring the patient’s good. To protect the age-old fiduciary or “trust” relationship between patients and clinicians requires a re-adjustment of current attitudes and practices – not just in the current cure-oriented health care of conventional medicine, but in the palliation-oriented health care of hospice as well. That is, it requires the development of attitudes and practices that foster a democratic, multidisciplinary process of shared decision-making and the adoption of a genuinely bio/psycho/social understanding and articulation of “the patient’s good” – irrespective of where along the continuum of care patients and clinicians find themselves.ZusammenfassungIn diesem Artikel wird die Entwicklung der Hospizbewegung in den USA untersucht und einige bedeutende Stärken und Schwächen beschrieben. Es wird argumentiert, dass – trotz anderwärtiger Vermutungen – auch die Hospizbewegung nicht immun gegen eine Verfremdung zwischen Arzt und Patient ist, die auf einer Überbetonung der biologischen Probleme sowie deren technologischer Lösungen beruht und das individuelle Ziel des Patienten (sein eigentliches Anliegen) übersieht. Um die altehrwürdige Tradition der Fürsorge und Treuhänderschaft zwischen Arzt und Patient aufrecht zu erhalten, bedarf es einer Änderung der üblichen Einstellungen und Praktiken, um einen demokratischen, interdisziplinären, gemeinsamen Entscheidungsprozeß zu ermöglichen. Ziel ist es, ein bio-psycho-soziales Verständnis der eigentlichen Patientenbedürfnisse (the patient’s good) während des gesamten Kontinuum der Arzt-Patient Beziehung zu finden.

Changing health care systems from ethical, economic, and cross cultural perspectives

1. Health Care Systems and Ethics E.H. Loewy. 2. Facing Finitude in Health L.R. Churchill. 3. Health Care as a Right E.-H.W. Kluge. 4. The Oregon Health Plan Ten Years Later M.J. Garland. 5. A Mortgage on the House of God P.A. Pugno. 6. Values in Medicine F.T. Fitzgerald. 7. Generational Conflicts and their Impact on Thinking about the Healthcare System R. Gronemeyer. 8. The Uninsured and the Rationing of Health Care D. Chinitz, A. Israeli. 9. Application and Implications of Deontology, Utilitarianism and Pragmatism for Medical Practice T. Cornelius. 10. The Old Ethics and the New Economics of Health Care B. Rich. 11. Playing the HMO Language Game R.Springer Loewy, E.H. Loewy. 12. Rationing Health Care in the United States and Canada W. Glannon. 13. Altering Capitation to Reduce the Incentive to Undertreat Patients Inappropriately R. Jaffe. 14. Cross Cultural Issues in Medicine J.K. Park. 15. Competing Interests in Pediatric Managed Care Settings S.E. Zinner-Kemp. Index.

Framing issues in health care: do American ideals demand basic health care and other social necessities for all?

This paper argues for the necessity of universal health care (as well as universal free education) using a different argument than most that have been made heretofore. It is not meant to conflict with but to strengthen the arguments previously made by others. Using the second paragraph of the Declaration of Independence and the Preamble to the Constitution we argue that universal health care in this day and age has become a necessary condition if the ideals of life, liberty and the pursuit of happiness are to be more than an empty promise and if the discussion of “promoting of general welfare” in the preamble is to have any meaning.

Playing the HMO Language Game

In emergency situations, patients who belong to one managed care organization are not rarely admitted to hospitals outside of those “recognized” by the organization to which the patient has subscribed or been assigned. In such situations every attempt is made by the managed care organization to which the patient is said to “belong” to effect a transfer from the admitting hospital to the particular “preferred provider” facility (PPO) of the health care organization or managed care plan. The managed care system calls this procedure “repatriation.” Pressure is brought to bear on the admitting hospital to transfer such patients at the first possible moment—sometimes with life sustaining equipment in place—and always in the middle of treatment. Such transfers are often against patients’ wishes. More importantly, because of the disruption in the continuity of professional caregivers they necessitate such transfers are also often against patients’ best interests. These disruptions are especially troubling when they occur within teaching hospitals where, in addition to being burdensome for patients, they hamper progress in research and in teaching and learning for both students and faculty alike.