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What do doctors think?
The close and dynamic relationship between medical ethics and medical practice is shown to be alive and well in this month’s issue, with three papers that examine various aspects of clinical practice and the attitudes of the medical profession.
A study by F A Miller and colleagues examines the attitudes of healthcare practitioners towards disclosure of incidental findings (such as carrier status) from newborn screening programmes (see page 626). The authors find considerable support for full disclosure largely on the basis of clinical duty, notwithstanding potential ethical concerns, but also a minority who supported reasons against disclosure, based on arguments such as the possibility of harm ensuing from disclosure or the right of the child to choose whether to seek this information in future. This study provides a useful empirical complement to more theoretical ethical arguments about disclosure of genetic information, and raises the questions of how prevailing clinical practices and beliefs ought to influence public policy in areas where there is ethical debate, and how dissenting opinions in such matters should be weighed.
Dwarswaard et al present a comparative study tracking changes in medical professional ethics in the Netherlands with respect to general practice and surgery (see page 621). They examine the evolution of practitioner attitudes within these two areas of medicine towards issues such as the doctor–patient relationship and the continuity of care. As well as descriptive and normative commentary on medical professional ethics within the country of study, such research may provide insights into the practice of medicine internationally—for example, an interesting comparison might be drawn between changes in GP attitudes in the Netherlands and the changing conditions of general practice medicine under the NHS in the UK.
Thirdly, we have a brief commentary by Cleary et al on the increasing phenomenon of locked psychiatric wards, identifying ethical, social and practical issues that pertain to this practice and warrant further discussion (see page 644).
Sport drugs, smart drugs
The subject of cognitive enhancement is always topical and has been considered from numerous different angles. A paper by V Cakic considers arguments often raised against the use of performance-enhancing drugs in sport and compares their application to the use of cognitive-enhancing drugs in academia (see page 611). The issues addressed cover concerns over unfair advantage and cheating, indirect coercion, safety, and the practical difficulties involved in regulation. The author notes that the level of risk in the use of cognitive enhancers will be a key factor in determining the appropriateness and necessity of regulation, and calls, as others have done, for further investigation into safety and efficacy aspects of cognitive-enhancing drugs in the healthy.
Death and vital organ donation
F G Miller revisits arguments advanced by Hans Jonas some 40 years ago against the then newly established criteria allowing the determination of biological death on the basis of brain death—a crucial factor in allowing vital organ transplantation—and uses these to address the issue of whether, given the increasing evidence that patients classed as brain-dead retain a wide array of biological functioning, we should continue to permit harvesting of vital organs from these patients (see page 616). Miller rejects Jonas’ objections to the procedure based on suffering, exploitation and lack of consent, but identifies the importance of the killing/letting die distinction in sustaining Jonas’ position against brain-dead organ procurement. If this distinction is not maintained, it is possible logically to reject the idea that brain death and biological death are equivalent, yet still to accept vital organ transplantation, as we also accept the withdrawal of life-sustaining treatment (letting die) under similar circumstances. This would essentially mean “abandoning the dead donor rule”, as Miller puts it, and allowing death by vital organ donation. As the author notes, such a major policy shift is unlikely to be accepted in the near future; however, as the alternatives are less philosophically and ethically coherent, perhaps eventually logic and consistency will prevail. The implications of this for vital organ donation from consenting, non-brain-dead patients remain to be explored.
Research ethics, body art and more
Two papers in this issue address different aspects of research ethics. Nakash et al contribute to the discourse over research participation by disadvantaged populations by examining issues in informed consent for young people from underprivileged communities in the developing world (see page 638). Their findings support the growing perception in research ethics that ethical guidelines for participation must be sensitive to the sociocultural context of the research. Schumm and colleagues, in their paper on historical anthrax vaccine studies (see page 594), elaborate on an issue somewhat broader than the usual focus of clinical research ethics: the ethical imperative for clarity, veracity and accuracy in the reporting of scientific research results, particularly where those results continue to form the foundation of public health policy that has potentially significant consequences.
Another two papers deal with the capacity for decision-making and its implications for policy and practice, in two rather different contexts, one medical and one non-medical. Szmukler considers issues in establishing mental capacity for treatment decisions among patients with “personality disorder” (see page 647), while Oultram examines the body-art practice of scarification and the arguments for allowing competent adults to participate in such procedures, but denying them to minors (see page 607).
Other offerings include a paper on conscientious objection to abortion, another on the ethical imperative for medical practitioners to treat patients’ pain appropriately, and, of course, episode 4 of Eyewitness in Erewhon Academic Hospital—the world’s longest-running bioethics journal fiction serial!