Journal of Bioethical Inquiry, Volume 11, Number 1 (March 2014)

Editorials

Two Deaths and a Birth: Reminiscing and Rehashing Principles in Biomedical Ethics

Michael A. Ashby and Leigh E. Rich

How Shall We Thank Thy Merit?

Michael A. Ashby and Leigh E. Rich

Letters to the Editor

A Pilot Survey of Consenting Practice for Laparoscopic Cholecystectomy

Irshad Shaikh, Mohamed Boshnaq, Ahmed Al-naher, Sapna Patel, and George Tsavellas

Recent Developments

Investigating Research and Accessing Reproductive Material

Trudo Lemmens and Bernadette J. Richards

Original Research

Market Liberalism in Health Care: A Dysfunctional View of Respecting “Consumer” Autonomy

Michael A. Kekewich
The unfortunately vast history of paternalism in both medicine and clinical research has resulted in perpetually increasing respect for patient autonomy and free choice in Western health care systems. Beginning with the negative right to informed consent, the principle of respect for autonomy has for many patients evolved into a positive right to request treatments and expect accommodation. This evolution of patient autonomy has mirrored a more general social attitude of market liberalism where increasing numbers of patients have come to embody the role of the “consumer.” This paper explores this transformation and critiques the current way in which respect for patient autonomy is put into practice. Ultimately, this paper concludes that the consumer view of patient autonomy is dysfunctional. Moreover, this paper argues that, based on the inherent goals of medicine, some form of paternalism is required in any meaningfully therapeutic relationship.

Anorexia Nervosa: The Diagnosis

Sacha Kendall
This paper argues that there is a relationship between understandings of anorexia nervosa (AN) and how the ethical issues associated with involuntary treatment for AN are identified, framed, and addressed. By positioning AN as a construct/discourse (hereinafter “AN: the diagnosis”) several ethical issues are revealed. Firstly, “AN: the diagnosis” influences how the autonomy and competence of persons diagnosed with AN are understood by decision-makers in the treatment environment. Secondly, “AN: the diagnosis” impacts on how treatment and treatment efficacy are defined and the ethical justifiability of paternalism. Thirdly, “AN: the diagnosis” can limit the opportunity for persons with AN to construct an identity that casts them as a competent person. “AN: the diagnosis” can thus inherently affirm professional knowledge and values. Postmodern professional ethics can support professionals in managing these issues by highlighting the importance of taking responsibility for professional knowledge, values, and power and embracing moral uncertainty.

The Incredible Complexity of Being? Degrees of Influence, Coercion, and Control of the “Autonomy” of Severe and Enduring Anorexia Nervosa Patients

Terry Carney
Commentary on “Anorexia Nervosa: The Diagnosis: A Postmodern Ethics Contribution to the Bioethics Debate on Involuntary Treatment for Anorexia Nervosa” by Sacha Kendall.

Treatment Refusal in Anorexia Nervosa: The Hardest of Cases

Christopher James Ryan and Sascha Callaghan
Commentary on “Anorexia Nervosa: The Diagnosis: A Postmodern Ethics Contribution to the Bioethics Debate on Involuntary Treatment for Anorexia Nervosa” by Sacha Kendall.

Making Sense of Child Welfare When Regulating Human Reproductive Technologies

John McMillan
Policy-makers have attempted to frame the ethical requirements that are relevant to the creation of human beings via reproductive technologies. Various reports and laws enacted in New Zealand, Canada, Australia, and Britain have introduced tests for how we should weigh child welfare when using these technologies. A number of bioethicists have argued that child welfare should be interpreted as a “best interests” test. Others have argued that there are ethical reasons why we should abandon this kind of test. I will argue that at least some of the relevant policy can be interpreted as requiring those wishing to exercise their procreative liberty to have a reasonable plan to care and nurture any resulting child, thereby respecting the internal preconditions of that liberty. This interpretation of child welfare requirements answers some of the ethical worries about a child welfare test.

Understanding Selective Refusal of Eye Donation

Mitchell Lawlor and Ian Kerridge
Corneal transplantation is the most common form of organ transplantation performed globally. However, of all organs, eyes have the highest rate of refusal of donation. This study explored the reasons why individuals decide whether or not to donate corneas. Twenty-one individuals were interviewed who had made a donation decision (13 refused corneal donation and eight consented). Analysis was performed using Grounded Theory. Refusal of corneal donation was related to concerns about disfigurement and the role of eyes in memory and communication. The request for donation therefore raised concerns about a potential adverse change in the ongoing relationship with the deceased, even in death. For those who refused donation, these concerns overshadowed awareness of need or benefit of transplantation. Adjusting the donation message to be more congruent with the real, lived experience of corneal donation may to some extent “prepare” individuals when the donation question is raised.

Dazed and Confused: Sports Medicine, Conflicts of Interest, and Concussion Management

Brad Partridge
Professional sports with high rates of concussion have become increasingly concerned about the long-term effects of multiple head injuries. In this context, return-to-play decisions about concussion generate considerable ethical tensions for sports physicians. Team doctors clearly have an obligation to the welfare of their patient (the injured athlete) but they also have an obligation to their employer (the team), whose primary interest is typically success through winning. At times, a team’s interest in winning may not accord with the welfare of an injured player, particularly when it comes to decisions about returning to play after injury. Australia’s two most popular professional football codes—rugby league and Australian Rules football—have adopted guidelines that prohibit concussed players from continuing to play on the same day. I suggest that conflicts of interest between doctors, patients, and teams may present a substantial obstacle to the proper adherence of concussion guidelines. Concussion management guidelines implemented by a sport’s governing body do not necessarily remove or resolve conflicts of interest in the doctor–patient–team triad. The instigation of a concussion exclusion rule appears to add a fourth party to this triad (the National Rugby League or the Australian Football League). In some instances, when conflicts of interest among stakeholders are ignored or insufficiently managed, they may facilitate attempts at circumventing concussion management guidelines to the detriment of player welfare.

Human Rights, Dual Loyalties, and Clinical Independence

Ryan Essex
Although Australia has comparatively few individuals seeking asylum, it has had a mandatory detention policy in place since 1992. This policy has been maintained by successive governments despite the overwhelmingly negative impact mandatory detention has on mental health. For mental health professionals working in this environment, a number of moral, ethical, and human rights issues are raised. These issues are discussed here, with a focus on dual loyalty conflicts and drawing on personal experience, the bioethics and human rights literature, and recent parliamentary inquiries. For those who continue to work in this environment, future directions are also discussed.

Drugs, Money, and Power: The Canadian Drug Shortage

Chris Kaposy
This article describes the shortage of generic injectable medications in Canada that affected hospitals in 2012. It traces the events leading up to the drug shortage, the causes of the shortage, and the responses by health administrators, pharmacists, and ethicists. The article argues that generic drug shortages are an ethical problem because health care organizations and governments have an obligation to avoid exposing patients to resource scarcity. The article also discusses some options governments could pursue in order to secure the drug supply and thereby fulfill their ethical obligations.

Reviews

Benevolence

Graeme C. Smith

Against Fairness

Paul T. Menzel

Tales From the Organ Trade

Katrina A. Bramstedt

Silver Linings Playbook

Katrina A. Bramstedt

The Words

Katrina A. Bramstedt

Case Studies

Competing Imperatives? Moral and Public Health Duties of Preventing and Treating Infectious Disease in Prisons

José de Arimatéia da Cruz and Leigh E. Rich