A compilation of 16 papers selected from two UNESCO Bangkok Bioethics Roundtables, with research and policy dialogues from different countries in the region. It includes papers on informed consent, ethics committees, communication, organ transplants, traditional medicines and sex selection.

Prayer has long been a staple in the proverbial Jewish medical toolbox. While the vast majority of relevant prayers seek renewed health and prolonged life, what might prayers for someone to die look like? What ethical dimensions are involved in such liturgical expressions? By examining both prayers for oneself to die and prayers for someone else to die, this essay discerns reasons why it may be good and even necessary to pray for a patient's demise.

Over the past 50 years, technical advances have taken place in medicine that have greatly increased the possibilities of life-prolonging intervention. The increased possibilities of intervening have brought along new ethical questions. Not everything that is technically possible is appropriate in a specific case: not everything that could be done should be done. In the 1980s, a new term was coined to indicate a class of inappropriate interventions: “medically futile treatment”. A debate followed, with contributions from the USA and several (...) western European countries. A similar debate later took place in Mediterranean countries, although with a different terminology. The purpose of this article is to provide an up-to-date and systematic analysis of the concept of futility, and to draw some conclusions on its operationalisation in medical practice. While the concept of “medical futility” in theory applies to all kinds of medical intervention that might be performed without being medically indicated—things such as certain medical screenings and cosmetic surgery—in practice the literature on “futility” deals only with life-saving and life-sustaining medical interventions. This article deals with this more limited application of the concept of “futility”. (shrink)

Dialogical ethics are a procedural alternative to substantive ethics such as consequentialism, deontology, principlism, casuistry, virtue ethics and care ethics. Dialogical ethics are procedural in that they do not establish goods in advance, unlike substantive ethics, but rather determine goods through a procedure enacted by the actual parties involved (although some substantive notion of justice may still be required); and they are dialogical in that the procedure is that of dialogue, involving both empathic critical discussion and negotiation. A fundamental tenet (...) of dialogical ethics may be the use of appropriate rules of order regulating dialogue among the parties involved. Some of the central characteristics of such rules of order are that they are reciprocally regulated by dialogue, that they override other ethical considerations, and that they institute empathic critical discussion and negotiation within the ethical dialogue. Dialogical bioethics are the application of dialogical ethics to ethical problems in medicine. The approach of dialogical bioethics has proven fruitful for resolving bioethical problems such as that of medical futility, where approaches of substantive ethics have reached an impasse. There is room for further study of special challenges within dialogical bioethics, such as the incompetence of some involved parties, conflicts of interests of third parties, and the cost-effectiveness of this ethical approach. (shrink)

BackgroundThe current debate about medical futility is mostly driven by theoretical and personal perspectives and there is a lack of empirical data to document experts and public attitudes towards medical futility.MethodsTo examine the attitudes of the Japanese experts in the fields relevant to medical futility a questionnaire survey was conducted among the members of the Japan Association for Bioethics. A total number of 108 questionnaires returned filled in, giving a response rate of 50.9%. Among the respondents 62% were healthcare professionals (...) (HCPs) and 37% were non-healthcare professionals (Non-HCPs).ResultsThe majority of respondents (67.6 %) believed that a physician's refusal to provide or continue a treatment on the ground of futility judgment could never be morally justified but 22.2% approved such refusal with conditions. In the case of physiologically futile care, three-quarters believed that a physician should inform the patient/family of his futility judgment and it would be the patient who could decide what should be done next, based on his/her value judgment. However more than 10% said that a physician should ask about a patient's value and goals, but the final decision was left to the doctor not the patient. There was no statistically significant difference between HCPs and Non-HCPs (p = 0.676). Of respondents 67.6% believed that practical guidelines set up by the health authority would be helpful in futility judgment.ConclusionThe results show that there is no support for the physicians' unilateral decision- making on futile care. This survey highlights medical futility as an emerging issue in Japanese healthcare and emphasizes on the need for public discussion and policy development. (shrink)

In this issue, Raphael Cohen-Almagor reviews some of the terms used in the discussion of bioethical issues at the end of a patient's life; he argues that they are “valueladen” and serve “primarily the physicians, at times at the expense of the patients’ best interest.” Each of the following terms comes under scrutiny: “death with dignity,” “persistent vegetative state,” “futility,” “double effect,” and “brain death.” He argues that these concepts, developed in recent decades, “have generated an unhealthy atmosphere for patients, (...) which might lead to undesirable actions at the end of patients’ lives.” He issues a plea to discontinue the use of the term “persistent vegetative state” because it is dehumanizing, to explain “double effect” and “futility” in detail and with sincerity, and to clarify the motivation for using these terms and others. He warns physicians not to use terminology that is offensive to patients and loved ones or that weakens their patients’ will to live. (shrink)

Wenn man davon ausgeht, dass eine der Voraussetzungen für ein gut fundiertes moralisches Urteil im Bereich der Medizin ein adäquates Verständnis der medizinischen Gegebenheiten und Zusammenhänge ist, dann muss diesem Aspekt bei der Beurteilung der künstlichen Ernährung bei fortgeschritten Demenzerkrankten in Zukunft mehr Aufmerksamkeit geschenkt werden. Damit verbunden ist die kritische Auseinandersetzung mit aktuellen empirischen Untersuchungen, anhand derer es gerechtfertigt scheint, die künstliche Ernährung bei dementen Patienten als erfolglos hinsichtlich des Ernährungszustands, der Verbesserung der Lebensqualität und der Überlebenszeit zu bezeichnen. (...) Unsere Arbeit setzt an drei wesentlichen Punkten an: zum einen soll der Zusammenhang zwischen Ernährungssituation und Demenzerkrankung dargestellt werden, andererseits soll ein Modell vorgestellt werden, das bessere Ergebnisse verspricht als sie in den bisherigen empirischen Studien gefunden worden sind, und drittens soll darauf aufmerksam gemacht werden, dass mit dem Erkennen der Möglichkeit der adäquaten Ernährung von fortgeschritten Demenzkranken auch neue Optionen in der normativen Beurteilung von künstlicher Ernährung offen stehen. (shrink)

ZusammenfassungWenn man davon ausgeht, dass eine der Voraussetzungen für ein gut fundiertes moralisches Urteil im Bereich der Medizin ein adäquates Verständnis der medizinischen Gegebenheiten und Zusammenhänge ist, dann muss diesem Aspekt bei der Beurteilung der künstlichen Ernährung bei fortgeschritten Demenzerkrankten in Zukunft mehr Aufmerksamkeit geschenkt werden. Damit verbunden ist die kritische Auseinandersetzung mit aktuellen empirischen Untersuchungen, anhand derer es gerechtfertigt scheint, die künstliche Ernährung bei dementen Patienten als erfolglos hinsichtlich des Ernährungszustands, der Verbesserung der Lebensqualität und der Überlebenszeit zu bezeichnen. (...) Unsere Arbeit setzt an drei wesentlichen Punkten an: zum einen soll der Zusammenhang zwischen Ernährungssituation und Demenzerkrankung dargestellt werden, andererseits soll ein Modell vorgestellt werden, das bessere Ergebnisse verspricht als sie in den bisherigen empirischen Studien gefunden worden sind, und drittens soll darauf aufmerksam gemacht werden, dass mit dem Erkennen der Möglichkeit der adäquaten Ernährung von fortgeschritten Demenzkranken auch neue Optionen in der normativen Beurteilung von künstlicher Ernährung offen stehen. (shrink)