We have a reason to use information which is available about such genes in our reproductive decision-making; (3) couples should selec.

The four principles approach to medical ethics plus specification is used in this paper. Specification is defined as a process of reducing the indeterminateness of general norms to give them increased action guiding capacity, while retaining the moral commitments in the original norm. Since questions of method are central to the symposium, the paper begins with four observations about method in moral reasoning and case analysis. Three of the four scenarios are dealt with. It is concluded in the “standard” Jehovah’s (...) Witness case that having autonomously chosen the authority of his religious institution, a Jehovah’s Witness has a reasonable basis on which to refuse a recommended blood transfusion. The author’s view of the child of a Jehovah’s Witness scenario is that it is morally required—not merely permitted—to overrule this parental refusal of treatment. It is argued in the selling kidneys for transplantation scenario that a fair system of regulating and monitoring would be better than the present system which the author believes to be a shameful failure. (shrink)

Over the course of its first seven editions, Principles of Biomedical Ethics has proved to be, globally, the most widely used, authored work in biomedical ethics. It is unique in being a book in bioethics used in numerous disciplines for purposes of instruction in bioethics. Its framework of moral principles is authoritative for many professional associations and biomedical institutions-for instruction in both clinical ethics and research ethics. It has been widely used in several disciplines for purposes of teaching in the (...) classroom, during conferences, etc. (shrink)

Between 1992 and 1996, a small number of women in the UK were forced by the courts to undergo caesarean section against their expressed refusal. Analysis of the reported cases reveals the blanket assumption of maternal incompetence and the widespread use of thinly veiled coercion. Such attitudes and practices are themselves frequently compounded by inadequate communication. Medical discretion in such problematic cases seems to err on the side of safety and so appears to favour the life of the fetus over (...) maternal autonomy. Despite current policy’s placement of the pregnant woman at the centre of maternity care, obstetricians’ concerns appear to lie more with the unborn fetus. In other words, there seems to be a point at which the value of fetal life begins to outweigh, not so much the life of the woman, but her right to self-determination, her plans and her choices. While it is important to acknowledge that these court ordered caesareans represent an unusual extreme within contemporary maternity care in this country, that they have happened brings into sharp relief some of the stereotypical assumptions about women. These are assumptions that underlie much of current medical practice and may compromise or disempower women in other ways during their experience of pregnancy and labour. Using the first and last of the six reported cases as contextual illustrations, this article focuses on the complex interplay of processes that have brought the medical profession to a position in which their own self-conviction and determination to do what they believe is best for their patients has resulted in gross denial of women’s autonomy and the use of the law to override pregnant women’s refusal of consent. (shrink)

In 1997, a Scottish surgeon by the name of Robert Smith was approached by a man with an unusual request: he wanted his apparently healthy lower left leg amputated. Although details about the case are sketchy, the would-be amputee appears to have desired the amputation on the grounds that his left foot wasn’t part of him – it felt alien. After consultation with psychiatrists, Smith performed the amputation. Two and a half years later, the patient reported that his life had (...) been transformed for the better by the operation [1]. A second patient was also reported as having been satisfied with his amputation [2]. (shrink)

This paper criticises the current approach of the courts to the problem of patients who refuse life-saving medical treatment. Recent judicial decisions have indicated that, so long as the patient satisfies the minimal test for capacity outlined in Gillick, the courts will not be concerned with the substantive grounds for the refusal. In particular, a 'rationality requirement' will not be imposed. This paper argues that, whilst this approach may accord with our desire to uphold the autonomy of a patient who (...) refuses treatment on religious grounds, it fails to address the problem of the deluded decision-maker whose refusal is based on wrongheaded reasons (and where talk of autonomy is a disservice). The difficulty can be overcome, however, by recognising that the two patients in fact inhabit at distinct realms-the non-rational and the irrational. The test for capacity, at least in the context of life-saving treatment, should revert accordingly to the older concept of 'sound mind', to disallow refusals of an irrational (as opposed to a non-rational) nature. (shrink)

Our aim is to expand the regulative ideal governing consent. We argue that consent should not only be informed but also based on rational beliefs. We argue that holding true beliefs promotes autonomy. Information is important insofar as it helps a person to hold the relevant true beliefs. But in order to hold the relevant true beliefs, competent people must also think rationally. Insofar as information is important, rational deliberation is important. Just as physicians should aim to provide relevant information (...) regarding the medical procedures prior to patients consenting to have those procedures, they should also assist patients to think more rationally. We distinguish between rational choice/action and rational belief. While autonomous choice need not necessarily be rational, it should be based on rational belief. The implication for the doctrine of informed consent and the practice of medicine is that, if physicians are to respect patient autonomy and help patients to choose and act more rationally, not only must they provide information, but they should care more about the theoretical rationality of their patients. They should not abandon their patients to irrationality. They should help their patients to deliberate more effectively and to care more about thinking rationally. We illustrate these arguments in the context of Jehovah's Witnesses refusing life-saving blood transfusions. Insofar as Jehovah's Witnesses should be informed of the consequences of their actions, they should also deliberate rationally about these consequences. (shrink)

The foreskin in small boys causes much anxiety in our society. It develops during the second half of gestation, and in premature infants may appear relatively deficient. By term, however, it has grown and protruded to well beyond the glans penis. The inner layer of the foreskin is densely adherent to the surface of the glans and cannot be retracted until it is fully separated, which occurs during the first few years of life. Prior to that time the distal opening (...) of the foreskin is narrow, but because of its adherence there is no significant pocket under the skin to allow accumulation of urine or debris. Later in childhood, after the foreskin is fully separated, urine and dirt can accumulate between the foreskin and the glans, leading to infection and inflammation . With recurrent balanitis, and/or tearing of the delicate foreskin, phimosis or scarring may constrict the distal foreskin.Circumcision has a long history in ancient societies of the Middle East, and is likely to have arisen as an early public health measure for preventing recurrent balanitis, caused by sand accumulating under the foreskin. Circumcision is a major part of the ritual for such religions as Judaism, Christianity, and Islam, and it is probably no accident that all of these arose in the Middle East. By contrast, in religions arising outside the arid Middle East , there is no ritual circumcision. In aboriginal society in Australia, circumcision is practised also.The importance of preventing recurrent balanitis and secondary phimosis in arid, sandy regions was confirmed by the Australian army medical corps in two world wars. During both wars, Australian soldiers were stationed in North Africa and the Middle East, and the incidence of recurrent balanitis caused by sand under the foreskin reached “epidemic” proportions, leading to large numbers …. (shrink)

The health benefits of male circumcision are wide rangingIn this issue, John Hutson has reiterated the conventional Western medical view that “the surgical argument for circumcision of all neonatal males at present is very weak” and he criticises many of the circumcisions performed in later childhood, without anaesthesia, as “physically cruel and potentially dangerous” [see page 238].1 He is also of the opinion that “the diseases which circumcision is able to prevent are uncommon or even rare”. But therein he errs, (...) and greatly errs.He cites only two publications dealing with the protective effect of male circumcision against HIV infection, and makes no mention of the important recent meta-analysis of Weiss, Quigley, and Hayes2 which shows conclusively from a large number of studies that …. (shrink)

In the UK in October 1992, Mrs S was forced to have a caesarean section despite her objections to such a procedure on religious grounds. The case once again called into question the obligations of women to the unborn, and also whether one person can be forced to undergo a medical procedure for the benefit of someone else. Re S, like the case of Angela Carder, is often discussed in terms of the conflict between maternal and fetal rights. This paper (...) looks instead at our obligations to save life in general-whether or not we are pregnant- and at the obligations of mothers to their children-whether they are born or unborn. Drawing on Judith Jarvis Thomson's distinction, it argues that minimal decency informs the duties which are owed to strangers, but that parents can be expected to behave as Good Samaritans towards their children. Finally, it is argued that even if mothers are ethically obliged to consent to caesarean sections which will save the lives of their babies, this does not necessarily mean that others are at liberty, or even obliged, to proceed with such operations without their consent. (shrink)

Parents’ freedom to choose infant male circumcision is the correct policyIndividuals and groups lobbying to have infant male circumcision prohibited or restricted often argue that the practice of routinely circumcising infants is unjustified. For instance, in this issue of the journal, John Hutson argues that it is virtually impossible to justify a policy in which the medical establishment should be able to embark on a “mass circumcision” campaign of 100% of the infant male population [see page 238].1Indeed, I would be (...) hard pressed to find anyone who could rationally disagree with this contention. However, this is because no one is currently arguing for the enactment of a policy that stipulates that all healthy male infants should be routinely circumcised . Arguments seeking to support a prohibition of “routine infant circumcision”, such as the one by Hutson, are arguing against a straw man—and a pitiful one at that.2 Such arguments only serve to misconstrue the debate and avoid engaging in the real and pressing issues concerning the legitimacy of the provision of this procedure.The questions that should be considered, and the ones which I shall be interested in discussing here, are what reasons are justifiable for allowing parents to choose to have their son circumcised? After well informed and careful deliberation should parents have the freedom to choose to have their son circumcised? These are the most relevant questions to be considered because there is a growing collection of citizens, medical practitioners, and lawyers who are currently lobbying for the practice of infant male circumcision to be outlawed—for example, there is a bioethicist who argues that the criminal law should be used …. (shrink)

This paper argues that doctors ought to make all things considered value judgments about what is best for their patients. It illustrates some of the shortcomings of the model of doctor as 'fact-provider'. The 'fact-provider' model fails to take account of the fact that practising medicine necessarily involves making value judgments; that medical practice is a moral practice and requires that doctors reflect on what ought to be done, and that patients can make choices which fail to express their autonomy (...) and which are based on mistaken judgments of value. If doctors are properly to respect patient autonomy and to function as moral agents, they must make evaluations of what their patients ought to do, all things considered. This paper argues for 'rational, non-interventional paternalism'. This is a practice in which doctors form conceptions of what is best for their patients and argue rationally with them. It differs from old-style paternalism in that it is not committed to doing what is best. (shrink)

Savulescu has recently introduced the "rational non-interventional paternalist" model of the patient-doctor relationship. This paper addresses objections to such a model from the perspective of an anaesthetist. Patients need to make their own decisions if they are to be fully autonomous. Rational non-interventional paternalism undermines the importance of patient choice and so threatens autonomy. Doctors should provide an evaluative judgment of the best medical course of action, but ought to restrict themselves to helping patients to make their own choices rather (...) than making such choices for them. (shrink)

Promoting respect for the four principles remains of great practical importance in ordinary medicineThis is a special edition of the journal to celebrate the contribution of Raanan Gillon to the field of medical ethics. The papers in this issue are from a festspiel in honour of Raanan held on the 17th of October 2003. The theme of the festspiel was method in medical ethics. Colleagues of Raanan were asked to outline their own approach to medical ethics, and how this differed (...) from the four principles approach advocated by Raanan, as applied to four hypothetical cases which are also reproduced in this issue of the journal.1It is a great privilege to be able to publish this series of papers, and Raanan’s reply, in the journal for several reasons.The first and most important of these is that they are a tribute to the enormous contribution Raanan has made to the field of medical ethics. Raanan has been a pioneer in medical ethics in the United Kingdom and beyond. He edited the Journal of Medical Ethics for over 20 years, retiring in 2001. He has been instrumental in establishing medical ethics as a discipline, particularly within medical schools, in the United Kingdom.2 His book Philosophical Medical Ethics is one of the classics.3While most people associate Raanan with his advocacy of the four principles, it is important to remember his approach is not restricted solely to application of the four principles. He is also one of the sharpest, wittiest, and most original thinkers in medical ethics. In a recent editorial,4—for example, Raanan disagreed with a judicial decision to impose separation of identical twins which caused the death of one twin. He described it as “hubris”. He argued that the …. (shrink)