The book offers an introduction to the moral concepts and value of health care. It is written by a moral philosopher, a doctor and a nurse and contains questions, cases and exercises which are suitable for medical, nursing and all students and commentators on health care. Moral dilemmas include consent, confidentiality, the giving or withholding of information, and the economics of health care. The issues of artificial reproduction, terminal care and the research and testing of drugs are addressed.

Competent patients who refuse life saving medical treatment present a dilemma for healthcare professionals. On one hand, respect for autonomy and liberty demand that physicians respect a patient’s decision to refuse treatment. However, it is often apparent that such patients are not fully competent. They may not adequately comprehend the benefits of medical care, be overly anxious about pain, or discount the value of their future state of health. Although most bioethicists are convinced that partial autonomy or marginal competence of (...) this kind demands the same respect as full autonomy, Israeli legislators created a mechanism to allow ethics committees to override patients’ informed refusal and treat them against their will. To do so, three conditions must be satisfied: physicians must make every effort to ensure the patient understands the risks of non-treatment, the treatment physicians propose must offer a realistic chance of significant improvement, and there are reasonable expectations that the patient will consent retroactively. Although not all of these conditions are equally cogent, they offer a way forward to assure care for certain classes of competent patients without abandoning the principle of autonomy altogether. These concerns reach past Israel and should engage healthcare professionals wary that respect for autonomy may sometimes cause avoidable harm. (shrink)

The author congratulates Dr Brian Hurwitz, who recently reported the successful “intimidation” of an elderly competent widow into accepting badly needed therapy for a huge ulcerated carcinoma. He reports approvingly of the Israeli Patients' Rights Law, enacted in 1996, which demands detailed informed consent from competent patients before permitting treatment. But the law also provides an escape clause which permits coercing a competent patient into accepting life-saving therapy if an ethics committee feels that if treatment is imposed the patient will (...) give his/her consent retroactively. He suggests this approach as an appropriate middle road between overbearing paternalism and untrammelled autonomy. (shrink)

The aim of this paper is to investigate whether or not ethical conflicts can be identified, analysed and solved using ethical principles. The relation between the physician and the patient with ischemic heart disease (IHD) as life style changes are recommended in a secondary prevention program is used as an example. The principal persons affected (the patient and his or her spouse) and the ethical principles (respect for autonomy, non-maleficence, beneficence and justice) are combined in a two dimensional model. The (...) most important person affected by the recommendations is the patient. His or her autonomy is challenged by the suggested life style changes, the purpose of which is to promote the future wellbeing and health of the patient. The spouse is indirectly involved in and affected by the process. He or she often feels neglected by caregivers. Ethical conflicts can both be identified and analysed using ethical principles, but often no solution is implied. Most (if not all) physicians would strongly encourage life style changes, but surprisingly there is no uncontroversial justification for this conclusion using principles. (shrink)