Bioethics

by Associate Professor Iustin Lupu PhD

Medical Bioethics course objectives

I. Knowledge (codes of bioethics, the four principles of bioethics, virtues and vices, euthanasia, human cloning, the human rights, the rights of the patient, etc.). II. Understanding of the medical practice bioethical aspects (respect for the rights of the patient, avoidance of malpraxis charges etc.). III. Practice bioethics (application of the principles of bioethics to clinical cases, decisional capacity assessment using Mini Mental State Examination, and Glasgow Coma Scale, arguments for and against euthanasia, medically assisted suicide, and human cloning, etc. ).

WHAT IS MEDICAL ETHICS?

Ethics is the application of values and moral rules to human activities. Bioethics is a subsection of ethics, actually a part of applied ethics that uses ethical principles and decision making to solve actual or anticipated dilemmas in medicine and biology. Put simply, ethics is the study of morality careful and systematic reflection on and analysis of moral decisions and behaviour, whether past, present or future. Morality is the value dimension of human decision-making and behaviour. The language of morality includes nouns such as rights, responsibilities and virtues and adjectives such as good and bad (or evil), right and wrong, just and unjust. According to these definitions, ethics is primarily a matter of knowing whereas morality is a matter of doing. Their close relationship consists in the concern of ethics to provide rational criteria for people to decide or behave in some ways rather than others.

What is Bioethics?
Ethics is the application of values and moral rules to human activities. Bioethics is a subsection of ethics, actually a part of applied ethics that uses ethical principles and decision making to solve actual or anticipated dilemmas in medicine and biology. Bioethics is a field that ranges from the anguished private and individual dilemmas faced by physicians or other healthcare workers at the bedside of a dying patient, to the terrible public and societal choices faced by citizens and legislators as they try to devise equitable health or environmental policies. Ency. of Bioethics, Post Stephen, G., Editor, (2004), Thomson-Gale, New York, pag. 278.

Bioethics is the study of ethical issues in the practice of medicine and biomedical research.
Encyclopedia of Business Ethics and Society, pag. 240, (2008), London, Sage Publications Bioethics is a more inclusive term for _ ethics in clinical medicine. It is normative ethics applied to decision making and public policy in the domains of biology, medicine, and health care. It is also concerned with matters of basic scientific research and with the social applications of biological knowledge and biomedical technology. It is a new, broad field of study that has arisen largely during the last few decades, as new powers, new choices, and new dilemmas have been opened up by the biological revolution. Encyclopedia of Public Health, (2008), New York, Springer Verlag, pag. 87.

Medical Ethics or Bioethics, is the study and application of moral values, rights, and duties in the fields of medical treatment and research. Medical decisions involving moral issues are made every day in diverse situations such as the relationship between patient and physician, the treatment of human and animal subjects in biomedical experimentation, the allocation of scarce medical resources, the complex questions that surround the beginning and the end of a human life, and the conduct of clinical medicine and life-sciences research. Microsoft Encarta 2006. 1993-2005 Microsoft Corporation. All rights reserved.
The field of biomedical ethics (or, simply, bioethics), a subdiscipline of ethicsthe philosophical study of moralityhas evolved. In essence, bioethics is the study of medical morality, which concerns the moral and social implications of health care and science in human life (Mappes & DeGrazia, 2005).

From: Essentials of nursing leadership and management / Diane K.Whitehead, Sally A.Weiss, Ruth M.Tappen. -- 5th ed (2010), Philadelphia, F. A. Davis Company, pag. 40

Major Issues in Bioethics

Most bioethics issues fall into five major themes: beginning of life, end of life, rights of patients, animal rights, and environmental protection and preservation. I. The beginning of life category includes traditional areas of controversy (such as contraception and termination of pregnancy) and issues that more recently arose as a result of biotechnological advances. The latter category includes cloning, embryonic stem cell research, fetal experimentation, fetal surgery, multifetal pregnancy reduction, artificial reproductive technologies, eugenics, genetic screening, and gene therapy. II. End-of-life issues include the injunction to preserve human life, assisted suicide and euthanasia, futility of end-of-life care, and allocation of medical resources. III. The rights of patients involve issues such as voluntary participation and informed consent for medical treatment, truth-telling (i.e., sharing all information with patients), doctor patient confidentiality, autonomy of patients, research on human subjects, the rights of the insured and the uninsured, and the fair allocation of limited resources.

IV. Animal rights issues include questions regarding the use of animals as research subjects, the respectful and humane treatment of laboratory animals, domesticated farm animals and pets, and proper treatment of animals in the wild. V. Environmental protection and preservation focus on minimizing the destruction of natural resources and habitats, preserving species, recovering and cleaning up fouled habitats, and reintroducing endangered species. Biotechnological advances have also led to novel bioethical conundrums, such as whether to alter species by genetic engineering and how to safely utilize genetically modified plants and animals so as not to harm humans or the environment or wreak havoc with the natural process of evolution.

Major Principles of Secular Bioethics

In 1979 Tom Beauchamp and James Childress proposed four principles of modern secular bioethics: respect for autonomy, nonmaleficence, beneficence, and justice. The principles, developed specifically to address issues in medical and environmental science, serve as cornerstones for the development of bioethical codes of behavior. The principle of respect for autonomy includes the patients or research subjects right to freely choose or reject treatment, and the liberty to act accordingly. Every patients autonomy is of paramount importance. The right of informed consent represents one aspect of this principle. Accordingly, patients should be educated and allowed to participate in decisions regarding their fate; patients should retain authority to determine what their course of treatment is. However, even patient autonomy has limits; for instance, many would agree that patients must be prevented from harming themselves. Euthanasia on demand is not legal in the United States.

The principle of nonmaleficence means that the physician or scientist should do no harm. Patients should not be injured in the course of treatment. This could also be expanded to include the environment and be understood as a directive to protect our natural world. The principle of beneficence directs medical practitioners and researchers to do good, promote patient welfare, devise ways to improve quality of life, and repair the world. The fourth principle, the principle of justice, focuses on fairness in allocating resources. For instance, social benefits such as health care services, including pharmaceutical drugs, diagnostic tests, donated organs, and medical expertise, should be distributed in a just manner. Likewise, social burdens such as taxes should be assessed fairly.

Bioethics CONTENTS Chapter 1. Ethics, morals and morality

1. 1. Definition of terms. 1. 2. Morals. The structure of moral phenomenon. 1. 2. 1. Moral consciousness. 1. 2. 2. Moral practice. 1. 3. Ethics. 1. 3. 1. The branches of ethics. 1. 3. 1. 1. Theoretical ethics. 1. 3. 1. 2. Deontological ethics. 1. 3. 1. 3. Teleological ethics. 1. 3. 1. 4. Virtues ethics. 1. 3. 2. Applied ethics.

1
1 2 2 9 10 11 11 12 14 16

Chapter 2. Bioethics
1. 2. 2. 2. 2.

31 1. Morals and the scientific progress. 34 2. Bioethical reflection, medicine and ethical pluralism. 36 3. Ethical dilemmas. Decision-making models for solving ethical dilemmas. 39 4. Guidelines for medical therapeutics. 41 5. Problems, principles, and bioethical norms. 41 43 44 48 52 56 59

Chapter 3. The principle of autonomy of the patient

3. 1. The consent for medical treatment. 3. 2. Capacity of the patient 3. 3. To tell or not to tell the truth to the patient? 3. 4. Voluntariness or the free choice of the patient 3. 5. Substitute decision-making 3. 6. Confidentiality

Chapter 4. The principle of non-maleficience

66 4. 1. The problem of double effect 66 4. 2. The problem of acts or omissions, or the to kill or let do die 67 4. 3. Ordinary and extraordinary means of treatment (or obligatory or optional means of treatment). 69

Chapter 5. The principle of beneficence

5. 1. Paternalism in health care.

72 74 76

Chapter 6. The principle of justice

Chapter 7. Ethical codes of professional conduct in medicine

7. 1. The Hippocratic Oath 7. 2. The Maimonides Prayer 79 7. 3. The Decalogue of Masci (Spanish doctor of the XX century) 7. 4. International Code of Medical Ethics (Geneva, 1948) 7. 5. The Deontological Code of the College of Romanian Physicians 7. 6. Bioethics and human rights. 7. 6. 1.Human Freedom Indicators 7. 6. 2. Press Freedom and assessment methodology 7. 7. The ethics of scientific research in medicine.

79 79 80 80 81 82 83 85

Chapter 8. The ethics side of suicide

8. 1. Suicide and parasuicide definitions. Types of suicide 8. 2. The epidemiology of suicide. 8. 3. Risk factors in suicide. 8. 4. Prevention and post-prevention in suicide.

88 93 99 105 108

Chapter 9. Euthanasia

111 9. 1. Types of euthanasia. 112 9. 2. Medically assisted suicide. 115 9. 3. For and against euthanasia and medically assisted suicide. 117 9. 4. National guidelines and attitudes concerning euthanasia and medically assisted suicide. 121 Chapter 10. Cloning 124 10. 1. History and definitions of cloning. 124 10. 2. Ethical controversies on the problems raised by human cloning. 127

Chapter 11. Terrorism and bioterrorism

11. 1. Terrorism 11. 2. Bioterrorism 11. 3. Genetically modified organisms and the new vectors for toxicity 11. 4. Biological agents, characteristics and effects 11. 4. 1. Anthrax 11. 4. 2. Smallpox 11. 4. 3. Botulism 11. 4. 4. Hemorrhagic fever Ebola 11. 4. 5. Pulmonary pest 11. 4. 6. Tularemia 11. 4. 7. Brucellosis 11. 4. 8. Cholera 11. 4. 9. Q fever 11. 5. Representative events from the history of biological warfare

131 131 132 135 138 139 140 140 141 141 141 142 143 143

Appendices Appendix 1. Mini Mental State Examination 147 Appendix 2. Glasgow Coma Scale 149 Appendix 3. Informed Consent Survey 150 Appendix 4. A Patients Bill of Rights 151 Appendix 5. Ten basic rights of women who work in the health care professions 152 Appendix 6. The European Bill of Patients Rights 153 Appendix 7. International Code of Nursing Ethics 154 Appendix 8. The Hippocratic Oath 155 The Prayer of Maimonides 155 The Decalogue of Masci 156 Appendix 9.World suicide rates (table for 1996-1998) 157 Appendix 10. World average rates of suicide, homicide, car accidents and other socio-medical relevant variables for the years 1995-1998. 160

Appendix 11. Inventory of Communicational Skills in medicine Appendix 12. Inventory of Communicational abilities (general). Appendix 13. Ethical Style Inventory. Appendix 14. Index of Human Freedom (United Nations, 1991) Appendix 15. The Mach IV questionnaire Appendix 16. A synthetic history of the human rights Appendix 17. French Declaration of the Rights of Man and Citizen Appendix 18. The Universal Declaration on Human Rights Appendix 19. Freedom in the World 2003-2006

161 162 164 166 167 168 169 170 174

Medical Ethics Manual

TABLE OF CONTENTS Introduction ..................................................................................................7 What is medical ethics? Why study medical ethics? Medical ethics, medical professionalism, human rights and law Conclusion Chapter One - Principal Features of Medical Ethics ....14 Objectives Whats special about medicine? Whats special about medical ethics? Who decides what is ethical? Does medical ethics change? Does medical ethics differ from one country to another? The role of the WMA How does the WMA decide what is ethical? How do individuals decide what is ethical? Conclusion

Chapter Two - Physicians and Patients ..................................34 Objectives Case study Whats special about the physician-patient relationship? Respect and equal treatment Communication and consent Decision-making for incompetent patients Confidentiality Beginning-of-life issues End-of-life issues Back to the case study

Chapter Three - Physicians and Society ................................62 Objectives Case study Whats special about the physician-society relationship? Dual loyalty Resource allocation Public health Global health Back to the case study

Chapter Four - Physicians and Colleagues .........................80 Objectives Case study Challenges to medical authority Relationships with physician colleagues, teachers and students Reporting unsafe or unethical practices Relationships with other health professionals Cooperation Conflict resolution Back to the case study

Chapter Five - Medical Research ................................................94 Objectives Case study Importance of medical research Research in medical practice Ethical requirements Ethics review committee approval Scientific merit Social value Risks and benefits Informed consent Confidentiality Conflict of roles Honest reporting of results Whistle blowing Unresolved issues Back to the case study

Chapter Six - Conclusion ................................................................ 112 Responsibilities and privileges of physicians Responsibilities to oneself The future of medical ethics Appendix A Glossary (includes words in italic print in the text) ....................................120 Appendix B Medical Ethics Resources on the Internet ..........123 Appendix C World Medical Association: Resolution on the Inclusion of Medical Ethics and Human Rights in the Curriculum of Medical Schools World-Wide, and World Federation for Medical Education: Global Standards for Quality Improvement Basic Medical Education ..................................................................125 Appendix D Strengthening Ethics Teaching in Medical Schools ..................................................................................127 Appendix E Additional Case Studies ..............................

Medical Ethics or Bioethics, is the study and application of moral values, rights, and duties in the fields of medical treatment and research. Medical decisions involving moral issues are made every day in diverse situations such as the relationship between patient and physician, the treatment of human and animal subjects in biomedical experimentation, the allocation of scarce medical resources, the complex questions that surround the beginning and the end of a human life, and the conduct of clinical medicine and life-sciences research. Since ethics deals with all aspects of human behaviour and decision-making, it is a very large and complex field of study with many branches or subdivisions.

Bibliography
1. 2. 3. 4. 5. 6. 7. Beauchamp, Tom, James F. Childress, (1989), Principles of biomedical ethics, New York, Oxford University Press. Cattorini Paolo, (2006), Bioetica. Metodo ed elementi di base per affrontare problemi clinici, Terza edizione aggiornata e ampliata, Milano, Masson S.p.A. Durand, Guy, Andre Duplantie, Yvon Laroche, Danille Laudy, (2000), Histoire de lEthique Mdicale et Infirmire; Montral, Presses de lUniversit de Montral Eckstein, Daniel, (1987), Life styles assessment, n Corsini Raymond, J., (ed), Concise Encyclopaedia of Psychology, New York, John Wiley & Sons. Engelhardt H. Tristram Jr., (1996), The Foundations of Bioethics, Second edition, New York, Oxford University Press.

Encyclopedia of Bioethics in five volumes, , Post Stephen, G., Editor, (2004), New York, Thomson-Gale

Etchells, Edward, Gilbert Sharpe, Carl Elliot, Peter Singer, (1996), La capacit de dcision, Canadian Medical Association Journal, 155: 657-661. 8. Etchells, Edward, Gilbert Sharpe, Phil Walsh, John R. Williams, Peter Singer, (1996), Le Consentement, Canadian Medical Association Journal, 155: 177-180. 9. Kahn Axel, Dominique Lecourt, (2004), Biothique et libert, Paris, PUF/Quadrige essai. 10. Kleinman, Irwin, Bailys Franoise, Sanda Rodgers, Peter Singer, (1997), La confidentialit, Canadian Medical Association Journal, 156: 521-524. 11. Singer Peter, and Viens, A. M., (2008), The Cambridge Textbook of Bioethics, Cambridge, Cambridge University Press. 12. World Health Association, (2009), Medical Ethics Manual, Edited by World Health Association. 13. Zanc, Ioan, Iustin Lupu, (2006) Bioetic medical. Principii, dileme, soluii. Ediia a III-a revzut i adugit, Cluj-Napoca, Editura Medical Universitar Iuliu Haieganu. Journals: Revista Romn de Bioetic, American Journal of Bioethics, Bioethics, Journal of Medical Ethics, Ethique et sant.

Types of values
The human life is just one example of a wide range of things that we find valuable, and a complete list of them would probably be impossible to create. Nicholas Rescher, though, classifies some basic values into these eight categories: 1. Material and physical value: health, comfort, physical security 2. Economic value: economic security, productiveness 3. Moral value: honesty, fairness, kindness 4. Social value: generosity, politeness, graciousness 5. Political value: freedom, justice 6. Aesthetic value: beauty, symmetry, grace 7. Religious value: piety, obedience, faith 8. Intellectual value: intelligence, clarity, knowledge Source : Pojman, Louis P., & James Fieser, (2009), Ethics. Discovering Right and Wrong, Sixth Edition, Belmont, CA, Wadsworth, Cengage Learning, pag. 47.

Rokeach Value Survey

Terminal values A comfortable life An exciting life A sense of accomplishment A world at peace Beauty of nature and of man Equality Family security Freedom Happiness Inner harmony Mature love National security Pleasure Salvation Self-respect Social recognition True friendship Wisdom Instrumental values Ambitious Broad-minded Capable Cheerful Clean Courageous Forgiving Helpful Honest Imaginative Independent Intellectual Logical Loving Obedient Polite Responsible Self-controlled

The Ten Commandments

1. Thou shalt have no other gods before me! 2. Thou shalt not make unto thee any graven image 3. Remember the Sabbath day, to keep it holy 4. Honour thy father and thy mother 5. Thou shalt not kill 6. Thou shalt not commit adultery 7. Thou shalt not steal. 8. Thou shalt not bear false witness against thy neighbor 9. Thou shalt not covet thy neighbour's wife 10. Thou shalt not covet thy neighbour's house, nor his manservant, nor his maidservant, nor his ox, nor his ass, nor any thing that is thy neighbour's.

The term, "Bioethics" was coined by Dr. Potter in 1970 (Bioethics, The Science of Survival. Persp. Biol. Med., 14: 127-153) as a bridge between science and humanity in the service of worldwide human health in a protective environment

The father of the Bioethics was the American biochemist specialized in Oncology, Potter Van Rensselaer (1911-2001) in his book: Bioethics: Bridge to the Future, 1971

The focus here is on medical ethics, the branch of ethics that deals with moral issues in medical practice. Medical ethics is closely related, but not identical to, bioethics (biomedical ethics). Whereas medical ethics focuses primarily on issues arising out of the practice of medicine, bioethics is a very broad subject that is concerned with the moral issues raised by developments in the biological sciences more generally. Bioethics also differs from medical ethics insofar as it does not require the acceptance of certain traditional values that are fundamental to medical ethics (like the principle of autonomy). As an academic discipline, medical ethics has developed its own specialized vocabulary, including many terms that have been borrowed from philosophy.

Ethics has been an integral part of medicine at least since the time of Hippocrates, the fifth century B.C.E. (before the Christian era) Greek physician who is regarded as a founder of medical ethics. From Hippocrates came the concept of medicine as a profession, whereby physicians make a public promise that they will place the interests of their patients above their own interests. In recent times medical ethics has been greatly influenced by developments in human rights. In a pluralistic and multicultural world, with many different moral traditions, the major international human rights agreements can provide a foundation for medical ethics that is acceptable across national and cultural boundaries

Medical ethics is also closely related to law. In most countries there are laws that specify how physicians are required to deal with ethical issues in patient care and research. In addition, the medical licensing and regulatory officials in each country can and do punish physicians for ethical violations. But ethics and law are not identical. Quite often ethics prescribes higher standards of behaviour than does the law, and occasionally ethics requires that physicians disobey laws that demand unethical behaviour. Moreover, laws differ significantly from one country to another while ethics is applicable across national boundaries. For this reason, the focus here is on ethics rather than law.

WHAT S SPECIAL ABOUT MEDICAL ETHICS? Compassion, competence and autonomy are not exclusive to medicine. However, physicians are expected to exemplify them to a higher degree than other people, including members of many other professions. Compassion, defined as understanding and concern for another persons distress, is essential for the practice of medicine. In order to deal with the patients problems, the physician must identify the symptoms that the patient is experiencing and their underlying causes and must want to help the patient achieve relief. Patients respond better to treatment if they perceive that the physician appreciates their concerns and is treating them rather than just their illness.

A very high degree of competence is both expected and required of physicians. A lack of competence can result in death or serious morbidity for patients. Physicians undergo a long training period to ensure competence, but considering the rapid advance of medical knowledge, it is a continual challenge for them to maintain their competence. Moreover, it is not just their scientific knowledge and technical skil s that they have to maintain but their ethical knowledge, skil s and attitudes as well, since new ethical issues arise with changes in medical practice and its social and political environment.

Autonomy, or self-determination, is the core value of medicine that has changed the most over the years. Individual physicians have traditionally enjoyed a high degree of clinical autonomy in deciding how to treat their patients. Physicians collectively (the medical profession) have been free to determine the standards of medical education and medical practice. As will be evident, both of these ways of exercising physician autonomy have been moderated in many countries by governments and other authorities imposing controls on physicians. Despite these challenges, physicians still value their clinical and professional autonomy and try to preserve it as much as possible. At the same time, there has been a widespread acceptance by physicians worldwide of patient autonomy, which means that patients should be the ultimate decision-makers in matters that affect themselves. There are many examples of potential conflicts between physician autonomy and respect for patient autonomy. Besides its adherence to these three core values (compassion, competence, autonomy), medical ethics differs from the general ethics applicable to everyone by being publicly professed in an oath such as the World Medical Association

Rational approaches:
As the study of morality, ethics recognises the prevalence of these non-rational approaches to decision-making and behaviour. However, it is primarily concerned with rational approaches. Four such approaches are deontology, consequentialism, principlism and virtue ethics: Deontology involves a search for well-founded rules that can serve as the basis for making moral decisions. An example of such a rule is, Treat all people as equals. Its foundation may be religious (for example, the belief that all Gods human creatures are equal) or non-religious (for example, human beings share almost all of the same genes). Consequentialism bases ethical decision-making on an analysis of the likely consequences or outcomes of different choices and actions. The right action is the one that produces the best outcomes. Of course there can be disagreement about what counts as a good outcome. One of the best-known forms of consequentialism, namely utilitarianism, uses utility as its measure and defines this as the greatest good for the greatest number

Principlism, as its name implies, uses ethical principles as the basis for making moral decisions. It applies these principles to particular cases or situations in order to determine what is the right thing to do, taking into account both rules and consequences. Principlism has been extremely influential in recent ethical debates, especially in the USA. Four principles in particular, respect for autonomy, beneficence, non-maleficence and justice, have been identified as the most important for ethical decision-making in medical practice Virtue ethics focuses less on decision-making and more on the character of decision-makers as reflected in their behaviour. A virtue is a type of moral excellence. As noted above, one virtue that is especially important for physicians is compassion. Others include honesty, prudence and dedication. Physicians who possess these virtues are more likely to make good decisions and to implement them in a good way. However, even virtuous individuals often are unsure how to act in particular situations and are not immune from making wrong decisions.

None of these four approaches, or others that have been proposed, has been able to win universal assent. Individuals differ among themselves in their preference for a rational approach to ethical decision-making just as they do in their preference for a nonrational approach Perhaps a combination of all four approaches that includes the best features of each is the best way to make ethical decisions rationally. It would take serious account of rules and principles by identifying the ones most relevant to the situation or case at hand and by attempting to implement them to the greatest extent possible. It would also examine the likely consequences of alternative decisions and determine which consequences would be preferable. Finally, it would attempt to ensure that the behaviour of the decision-maker both in coming to a decision and in implementing it is admirable. Such a process could comprise the following steps: 1. Determine whether the issue at hand is an ethical one. 2. Consult authoritative sources such as medical association codes of ethics and policies and respected colleagues to see how physicians generally deal with such issues. 3. Consider alternative solutions in light of the principles and values they uphold and their likely consequences. 4. Discuss your proposed solution with those whom it will affect. 5. Make your decision and act on it, with sensitivity to others affected. 6. Evaluate your decision and be prepared to act differently in future.

The Centers for Bioethics

In the 70's, the debates, and their participants, moved from conferences to permanent centers with the founding of the Hastings Center, the Kennedy Institute of Ethics at Georgetown University, and the Society for Health and Human Values. The ideas, literature and people involved in these early "think tanks" eventually identified the nature, the subject matter, and the methods peculiar to the new field of secular bioethics as we know it today, and especially how and when it is to be applied in public policy.

A. The Hastings Center:

In 1969, Willard Gaylin and Daniel Callahan (long time member and Director of the American Eugenics Society)36 founded the Hastings Center, funded primarily by the individuals John D. Rockefeller III and Elizabeth Dollard, as well as by the National Endowment for the Humanities and the Rockefeller Foundation.

The Kennedy Institute of Ethics:

The Kennedy Institute of Ethics at Georgetown University was also spawned during this time period. Andre Hellegers was a Jesuit-trained Dutch physician who was working at Johns Hopkins in research in fetal physiology and the reproductive sciences -- eventually earning him a Fellowship from the Joseph P. Kennedy, Jr. Foundation. In 1967 he came to Georgetown University School of Medicine, and was also the Director of Georgetown's Center for Population Research which was funded by a Ford Foundation Grant.

Aristotle's Virtues I. Defining Virtue in General Virtue = a means between two extremes, an excess and a defect, with respect to a particular action or emotion. II. Defining Specific Virtues 1. Courage is a means between the extremes of cowardice and foolhardiness with respect to the emotion of fear 2. Temperance is a means between the the extremes of selfindulgence and insensibility with respect to the desire for pleasures of the body (eating, drinking, sex). 3. Generosity (or liberality) is a means between the extremes of extravagance and stinginess with respect to the giving away and taking in of money. [an extravagant person is excessive in giving away , but defective in taking in money; a stingy person is defective in giving away money, but excessive in taking in it]. 4. Pride is a means between the extremes of vanity and excessive humility with respect to ones desire to receive great honors. 5. Good temper is a means between the extremes of irascibility (or irritability) and apathy with respect to ones proneness to anger.

6. Truthfulness is a means between the extremes of boastfulness and selfdeprecation with respect to the way one presents oneself to others. 7. Wittiness is a means between the buffoonery and boorishness with respect to ones desire to amuse others. 8. Friendliness is a means between obsequiousness (e.g., being overly deferential/groveling- or humiliation, servility) and unpleasantness with respect to the desire to please others. 9. Modesty is a means between the extremes of bashfulness and shamelessness with respect to one's susceptibility to shame. 10. Righteous indignation is a means between envy and spite with respect to the pleasure and pain that one feels at the fortunes of one's neighbors [e.g., One who is righteously indignant is pained by the undeserved good/bad fortune of others, but is pleased by the deserved good/bad fortune of others; the envious person is pained by the good fortune of others, whether deserved or not; the spiteful person feels pleasure at the bad fortune of others, whether they deserve it or not]

Virtue Courage Temperance Generosity Pride Good Temper Truthfulness Wittiness Friendliness Modesty Righteous Indignation

Domain Fear Desire for Pleasure Giving Money Away Desire for Honors Proneness to Anger Self-Presentation

Excess Cowardice

Defect Foolhardiness

Self-Indulgence Insensibility Extravagance Stinginess Vanity Irascibility Boastfulness Humility Apathy SelfDeprecation Boorishness Shamelessness Spite

Desire to Amuse Others Buffoonery Susceptibility to Shame Bashfulness Reaction to Other's Fortunes Envy

Desire to Please Others Obsequiousness Unpleasantness

ARISTOTLE'S NICOMACHEAN ETHICS /TABLE OF VIRTUES AND VICES

SPHERE OF ACTION OR FEELING Fear and Confidence Pleasure and Pain Getting and Spending (minor) Getting and Spending (major) Honour and Dishonour (major) Honour and Dishonour (minor) Anger Self-expression Conversation Social Conduct Shame Indignation

EXCESS Rashness Licentiousness/Selfindulgence Prodigality

MEAN Courage Temperance Liberality

DEFICIENCY Cowardice Insensibility Illiberality/Meanness

Vulgarity/Tastelessness

Magnificence

Pettiness/Niggardliness

Vanity

Magnanimity Proper ambition/pride Patience/Good temper Truthfulness Wittiness Friendliness Modesty Righteous indignation

Pusillanimity Unambitiousness/undue humility Lack of spirit/unirascibility Understatement/mock modesty Boorishness Cantankerousness Shamelessness Malicious enjoyment/Spitefulness

Ambition/empty vanity Irascibility Boastfulness Buffoonery Obsequiousness Shyness Envy

Christian virtues
The Cardinal Virtues: prudence, courage, temperance, justice Classical Greek philosophers considered the foremost virtues to be prudence, temperance, courage, and justice. Early Christian Church theologians adopted these virtues and considered them to be equally important to all people, whether they were Christian or not. The Theological Virtues: love, hope, faith.

Seven Deadly Sins: (demons) pride, (Lucifer) envy, (Leviathan) gluttony, (Belzeebub) lust, (Asmodeus)

anger, (Satan) greed, (Mammon) sloth.(Belphegor)

The Seven Heavenly Virtues: faith, hope, charity, fortitude, justice, temperance, prudence The Heavenly Virtues combine the four Cardinal Virtues: prudence, temperance, fortitude -- or courage, and justice, with a variation of the theological virtues: faith, hope, and charity.
The Seven Corporal Works of Mercy Continuing the numerological mysticism of Seven, the Christian Church assembled a list of seven good works that was included in medieval catechisms. They are: feed the hungry, give drink to the thirsty, give shelter to strangers, clothe the naked, visit the sick, minister to prisoners, and bury the dead.

The thirteen moral virtues listed by Benjamin Franklin in his Autobiography: 1. Temperance. Eat not to Dullness. Drink not to Elevation. 2. Silence. Speak not but what may benefit others or yourself. Avoid trifling Conversation. 3. Order. Let all your Things have their Places. Let each Part of your Business have its Time. 4. Resolution. Resolve to perform what you ought. Perform without fail what you resolve. 5. Frugality. Make no Expense but to do good to others or yourself: i.e. Waste nothing. 6. Industry. Lose no Time. Be always employed in something useful. Cut off all unnecessary Actions. 7. Sincerity. Use no hurtful Deceit. Think innocently and justly; and, if you speak, speak accordingly.

8. Justice. Wrong none, by doing Injuries or omitting the Benefits that are your Duty. 9. Moderation. Avoid Extremes. Forbear resenting Injuries so much as you think they deserve. 10. Cleanliness. Tolerate no Uncleanness in Body, Cloths or Habitation. 11. Tranquility. Be not disturbed at Trifles, or at Accidents common or unavoidable. 12. Chastity. Rarely use Venery but for Health or Offspring; Never to Dullness, Weakness, or the Injury of your own or another's Peace or Reputation. 13. Humility. Imitate Jesus and Socrates. Also... The Morning Question, What Good shall I do this Day? The Evening Question, What Good have I done today?

Eighteen Essential Virtues

1. Politeness (politesse, politee) 2. Fidelity (fidlit, devotement, loialitate) 3. Prudence (prudence, pruden) 4. Temperance (temprance, sobrit, cumptare) 5. Courage (courage, curaj) 6. Justice (justice, justiie) 7. Generosity (gnrosit, generozitate) 8. Compassion (compassion, compasiune, mil) 9. Mercy (clmence, caritate) 10. Gratitude (gratitude, reconnaissance, recunotin) 11. Humility (humilit, umilina) 12. Simplicity (simplicit, naturalee, lips de prefctorie) 13. Tolerance (tolrance, toleran) 14. Purity (puret morale, puritate a caracterului, ) 15. Gentleness (douceur, amabilit, amabilitate, gentilee) 16. Good faith (bonne foi, bun credin) 17. Humor (le sens de l'humeur, simul umorului) 18. Love (three forms: eros, philia, and agape) amour, iubirea cu trei forme: eros, filia i agape Comte-Sponville, Andr, Small Treatise on the Great Virtues (London: Vintage, 2003). Petit trait des grandes vertus, PUF, 1995 (Prix La Bruyre de l'Acadmie Franaise), rdite. Points-Seuil, 2001.

Much of the history of philosophy is the history of ethics. From Plato to Sartre, the great philosophers have returned to the central ethical questions of how we are to live good lives; how is it appropriate and virtuous for us to behave, both to ourselves and to others? "In addressing these questions, Andr Comte-Sponville returns to the mainstream of much of the Western philosophical traditon with an utterly original exploration of the timeless human virtues. "A Short Treatise on the Great Virtues takes as its starting point eighteen human virtues [politeness, fidelity, prudence, temperance, courage, justice, generosity, compassion, mercy, gratitude, humility, simplicity, tolerance, purity, gentleness, good faith, humour, love] to help us understand 'what we should do, who we should be, and how we should live'. ComteSponville offers the reader both a thoughtful and accessible introduction to the history of Western ethics and an exploration of the ways in which the views and claims of the great philosophers can apply--and fail to apply--to our lives today."

Gandhi's Seven Deadly Social Sins Mohandas Karamachand Gandhi, one of the most influential figures in modern social and political activism, considered these traits to be the most spiritually perilous to humanity. Wealth without Work Pleasure without Conscience Science without Humanity Knowledge without Character Politics without Principle Commerce without Morality Worship without Sacrifice

Eight Collective sins (Lorenz)

1. Overpopulation, which turns a society into a behavioral sink and reinforces the

other sins. 2. Devastation of the natural environment, with consequent atrophy of our esthetic and ethical feelings. 3. Ruthless "intraspecific" competitiveness, which in the absence of effective "extra-specific" influences, "works in direct opposition to all the forces of nature, destroying all the values they have created" 4. Entropy of feeling, an increased sensitiveness to unpleasurable experience combined with a decreased capacity for pleasure and a childish insistence of instant gratification 5. Genetic decay, the loss through domestication, through the loss of extraspecific selecting pressures, of "all delicately differentiated behavior patterns of courtship and pair formation" an of our natural sense of justice 6. Break with tradition, with culture, a body of adaptive knowledge that "has grown by selection in the same way as it develops in an animal species" and that is just as hard to begin from scratch as a new species of animal; plus the consequent conflict between generations 7. Easy indoctrinability of modern man, especially by behaviorist ideology -- "the present-day rulers of America, China and the Soviet Union are unanimous in one opinion: that unlimited conditionality of man is highly desirable." 8. Willingness, resulting from the first seven sins, to manufacture and use weapons of mass destruction.

The Characters of Theophrastus (Vices of human character)

I. The Ironical Man (v) Irony, roughly defined, would seem to be an affectation of the worse in word or deed. II. The Flatterer (i) Flattery may be considered as a mode of companionship degrading but profitable to him who flatters. III. The Garrulous Man (xviii) Garrulity is the discoursing of much and ill-considered talk. IV. The Boor (xiv) Boorishness would seem to be ignorance offending against propriety. V. The Complaisant Man (ii) Complaisance may be defined as a mode of address calculated to give pleasure, but not with the best tendency.

VI. The Reckless Man (xvi) Recklessness is tolerance of shame in word and deed. VII. The Chatty Man (xix) Chattiness, if one should wish to define it, would seem to be an incontinence of talk. VIII. The Gossip (xx) Gossip is the framing of fictitious saying and doings at the pleasure of him who gossips. IX. The Shameless Man (xv) Shamelessness may be defined as neglect of reputation for the sake of base gain. X. The Penurious Man (xiv) Penuriousness is too strict attention to profit and loss. XI. The Gross Man (xvii) Grossness is not difficult to define; it is obtrusive and objectionable pleasantry.

XII. The Unseasonable Man (ix) Unseasonableness consists in a chance meeting disagreeable to those who meet. XIII. The Officious Man (x) Officiousness would seem to be, in fact, a well-meaning presumption in word or deed (impertinence). XIV. The Stupid Man (xiii) Stupidity may be defined as mental slowness in speech and action. XV. The Surly Man (iii) Surliness is discourtesy in words. XVI. The Superstitious Man (xxviii) Superstition would seem to be simply cowardice in regard to the supernatural. XVII. The Grumbler (xxii) Grumbling is undue censure of ones portion.

XVIII. The Distrustful Man (xxiii) Distrustfulness is a presumption that all men are unjust. XIX. The Offensive Man (xii) Offensiveness is distressing neglect of person. XX. The Unpleasant Man (xi) Unpleasantness may be defined as a mode of address which gives harmless annoyance. XXI. The Man of Petty Ambition (vii) Petty ambition would seem to be a mean craving for distinction. XXII. The Mean Man (xxv) Meanness is an excessive indifference to honour where expense is concerned. XXIII. The Boastful Man (vi) Boastfulness would seem to be, in fact, pretension to advantages which one does not possess.

XXIV. The Arrogant Man (iv) Arrogance is a certain scorn for all the world beside oneself. XXV. The Coward (xxvii) Cowardice would seem to be, in fact, the shrinking of the soul through fear. XXVI. The Oligarch (xxix) The Oligarchical temper would seem to consist in a love of authority, covetous, not of gain, but of power. XXVII. The Late-Learner (viii) Late-learning would seem to mean the pursuit of exercises for which one is too old. XXVIII. The Evil-Speaker (xxi) The habit of Evil-speaking is a bent of the mind towards putting things in the worst light. XXIX. The Patron of Rascals (xxx) The Patronising of Rascals (villains) is a form of the appetite for vice. XXX. The Avaricious Man (xxvi) Avarice is excessive desire of base gain.

Classification of Character Strengths

I. Wisdom and knowledgecognitive strengths that encompass both attaining and using knowledge Creativity [originality, ingenuity]: Thinking of original and productive ways to conceive and accomplish things; according to Peterson and Seligman, creative efforts include artistic achievement but are not limited to them Curiosity [interest, novelty-seeking, openness to experience]: Being interested in experience for the sake of experience; finding the exploration and discover of a wide range of subjects and topics fascinating Open-mindedness [judgment, critical thinking]: Being willing and able to examine things from all sides; not jumping to conclusions; being willing and able to change ones mind in light of new evidence; being impartial in weighing all evidence Love of learning: Mastering new skills, subjects, and bodies of knowledge, whether individually or through others; closely related to the strength of curiosity but goes further in emphasizing the tendency to systematically add to ones knowledge base Perspective [wisdom]: Being able to provide astute advice to peers; having insights into looking at the world that make sense to others and oneself

II. Courageemotional strengths that involve the exercise of will to accomplish objectives in the face of adversity Bravery [valor]: Not shrinking from threat, challenge, difficulty, or pain; speaking up for what is right even if one has the minority opinion; the definition of bravery is not limited to the physical component Persistence [perseverance, industriousness]: A finisher; one who persists in a course of action despite setbacks; taking pride in completing tasks Integrity [authenticity, honesty]: Speaking the truth, being genuine and acting in a sincere way; being without pretense, able and willing to take responsibility for ones actions Vitality [zest, enthusiasm, vigor, energy]: Approaching life with excitement and energy; always willing to give 100%; having a viewpoint that life is to be lived to its fullest

III. Humanityinterpersonal strengths that involve the consideration of others Love: Close relations with others are important, in particular those relations predicated on sharing and caring Kindness [generosity, nurturance, care, compassion, altruistic love, niceness]: Wil ing and able to do favors and good deeds for others; being caring and helpful Social intel igence [emotional intel igence, personal intel igence]: Being cognizant of the motives and feelings of others; intuitively knowing how to fit in to a wide range of social situations

IV. Justicecivic strengths that underlie a healthy communitarian lifestyle Citizenship [social responsibility, loyalty, teamwork]: Working well in teams or groups; committed to the team; willing to do ones part Fairness: The ability to treat everyone equally; not letting personal feelings unduly influence ones decisions; giving everyone a fair shot Leadership: Being able to influence others to get things done, while maintaining good relations within the group; organizing, coordinating and monitoring group activities V. Temperancestrengths that buffer against excess Forgiveness and mercy: Forgiving those who have done wrong; accepting our limitations and those of others; willing to give others another chance; not being vengeful Humility/Modesty: Letting ones achievements do the talking; not seeking the center stage; not putting on false airs, not being a prima donna
Prudence: Being careful about ones choices; not undertaking unnecessary risks; being careful not to say or do things that could be regretted in the future Self-regulation [self-control]: Regulating what one feels and does; demonstrating discipline; controlling ones visceral appetites and emotions

VI. Transcendencestrengths that foster interconnections to the larger universe and provide one meaning Appreciation of beauty and excellence [awe, wonder, elevation]: Being aware and appreciating beauty, excellence, and/or skilled performance in various domains of life Gratitude: Being cognizant of and thankful for the many good things that happen; taking time out to smell the roses Hope [optimism, future-mindedness, future orientation]: Expecting the best in the future and being willing to work hard to achieve it; believing that a good future is something that can be brought about with ones efforts Humor [playfulness]: Liking to laugh and play; working to bring joy and good humor to other people; whenever possible, seeing the bright side; making (not necessarily telling) jokes Spirituality [religiousness, faith, purpose]: Having a well-articulated system of beliefs about the higher purpose and meaning of the universe; knowing where one fits within the larger picture; these beliefs about the meaning of life both provide comfort and help shape ones conduct. Note: Adapted from Peterson and Seligman (2004: 29-30). Character strengths and virtues: A handbook and classification. New York: Oxford University Press/Washington, DC: American Psychological Association.

Medical virtues
Hippocratic tradition Modesty Sobriety Patience Promptitude Respect /piety for human life

American Medical Association (AMA) Purity of character Diligence Justice Prudence Self-control Equity

Ethical dilemmas in medical practice

Individual values, beliefs, and personal philosophy play a major role in the moral or ethical decision making that is part of the daily routine of all doctors. How do doctors decide what is right and what is wrong? What does the doctor do if no right or wrong answer exists? What if both answers are right or wrong? Ethical dilemmas can be defined as having to choose between two equally desirable or undesirable alternatives. Curtin (1982) maintains that in order for a problem to be am ethical dilemma, it must have three characteristics. First, the problem cannot be solved using only empirical data. Second, the problem must be so perplexing that deciding what facts and data need to be used in making the decision is difficult. Third, the results of the problem must affect more than the immediate situation there should be far- reaching effects.

Traditional Problem-Solving Process Model for solving ethical dilemmas

1. 2. 3. 4. 5. 6. 7. Identify the problem Gather data to analyze the causes and consequences of the problem Explore alternative solutions Evaluate the alternatives Select the appropriate solution Implement the solution Evaluate the results

The MORAL Decision-Making Model Crisham (1985) developed a model for ethical decision making incorporating the nursing process and principles of biomedical ethics. The model is especially useful in clarifying ethical problems that result from conflicting obligations. This model is represented by the mnemonic MORAL, representing: M massage the dilemma. Collect data about the ethical problem and who should be involved in the decision- making process O outline options. Identify alternatives and analyze the causes and consequences of each. R review criteria and resolve. Weight the options against the values of those involved in the decision. This may be done through a weighting or grid. A affirm position and act. Develop the implementation strategy. L look back. Evaluate the decision making.

The Murphy and Murphy Approach to Ethical Decision Making

Murphy and Murphy (1976) developed a systematic approach to ethical decision making. 1. Identify the problem 2. Identify why the problem is an ethical problem 3. Identify the people involved in the ultimate (final) decision 4. Identify the role of the decision maker 5. Consider the short-term and long-term consequences of each alternative 6. Make the decision 7. Compare the decision with the decision makers philosophy of ethics Follow up on the results of the decision in order to establish a baseline for future

Ethical dilemmas perceived and reported by fourth-year students

Categories of Ethical Issues. Examples of Issues Coded Within the Category 1. Patient lacks resources. Patient cannot pay for services outlined in treatment plan. Patients insurance carrier does not cover treatment planned. 2. Conflict between clinicians. Treatment already planned for extraction, but student unable to identify carious lesion on specified tooth. Staff tell student how to plan or implement treatment not consistent with students plan. 3. Practices or policies inconsistent with standard of care. Failure to follow universal precautions. Overprescribing antibiotics. 4. Identifying the appropriate surrogate decision maker. Surrogate is unavailable. No surrogate is identified, but the patient is unable to make decisions.

5. Patients capacity to make decisions. Patient with dementia refuses extraction of unrestorable tooth. 6. Patient/parent demand for different treatment plan. Patient requests extraction of restorable or healthy tooth. Patient demands/seeks narcotics that are not clinically indicated. 7. Patient/parent refusal of treatment plan. Parent requests extraction of restorable tooth because it is faster and parent needs to return to work. 8. Patients dental health neglected by a caregiver. Child experiences long-term dental pain before parent/caregiver seeks care. 9. Student competence or confidence in own skills. Uncertain how to manage patients with behavioral problems. Uncertain how to manage patients with overwhelming fear of pain/dentist. 10. Difficult patients. Patient yells at student or staff. Patient is routinely late or absent for appointments.

11. Truth telling/disclosure. Patient not informed of all treatment options because of presumed inability to pay. 12. Mistakes. Student extracts wrong tooth. 13. Treatment with inadequate consent or assent from the patient or surrogate. Mother agrees to treatment, but cannot read or speak English. Treating a child without parental consent because accompanying adult is not the legal guardian. 14. Cultural issues. Communication inadequate because of lack of translator. Patients decisions seem to be influenced by values not shared by the student. 15. Breaking bad news. Identify a lesion consistent with mandibular cancer; need to refer the patient for biopsy. 16. Breach of confidentiality. Informal discussion (gossip) about a patient among the staff. 17. Other. Patient alters own narcotic prescription from 3 to 30.

Source: Sharp Helen M, et al. (2005), Ethical Dilemmas Reported by Fourth-Year Dental Students, Journal of Dental Education, 69: 1116-1121.

Types of ethical dilemmas faced by students,

with examples and quotations from focus groups Type of ethical dilemma (No of students reporting the problem) Examples Illustrative quotations from students Conflict between medical education and patient care (17) Patients asked to return to clinic for follow up visits and not informed that the visits were entirely for teaching purposes House officer instructed a student to perform a femoral puncture, for purely educational reasons, on a comatose patient who did not need the procedure Students asked to perform pelvic examinations on patients under general anaesthesia without patients' prior consent Patient's name and details of care discussed by staff and students in a public place

Case: Once, when I was on call, there was a patient who was palliative, in a vegetative state.
The resident [house officer] I was working with decided that this would be a good opportunity for me to learn how to do a femoral stab, even though it was not necessarily medically required. The patient was not expected to [recover] from his current condition, and wasn't in a position to argue, and I think there was a very thinly veiled excuse that we could do it. It was more or less for the exercise in education on a non-consenting patient. It struck me as so at the time too, but we don't really get a lot of opportunity to practise those types of procedures.

Responsibility exceeding student's capabilities (15)

Student completed antenatal visits with patients who were never seen by a doctor House officer refused to respond to student's request for help in assessing an unstable patient Student and house officer left by teacher to close a wound, without knowing how to close it properly Student expected to give weekly psychotherapy sessions without supervision

Case: I had one [an ethical dilemma] on obstetrics, being asked to go get a consent for a dilatation and curettage. I was on call at a peripheral hospital on the weekend. No resident; just the staff [consultant]. The staff wasn't the most cooperative. And so I went and did it. But I checked with the patient: Did the staff talk with you about the complications and the risks and the expectations? Because, frankly, I would not be capable of doing that. The patient said Yes, yes, yes, and I documented that I didn't do the discussion [and that] the staff did the discussion. And on the consent [form] I put my name and CC3 [denoting medical student status] in big letters after it, but I still thought it was ridiculous.

Involvement in care perceived to be substandard (9)

Student witnessed house officer responding inappropriately to patient's refusal to have joint aspiration; consent form completed, but consent not meaningfully given Student instructed by house officer to repair a child's scalp laceration with inappropriate supplies Patient requested a narcotic-free vaginal delivery but given intravenous narcotics without her knowledge Student uncomfortable about inadequate pain relief in patient care; felt it was `constantly put off' by house officer

Case: On my medical rotation, there was a patient on the floor who had lung cancer but [the physicians] weren't sure [of the type]. Nobody would tell the patient that he had cancer. The pathology report said that it was very suspicious for malignant cells. Anyone with any sort of medical training would know that the chances of it being malignant were very high. [Yet] nobody talked to the pathologist to find out what information they could tell the patient based on that. I asked the pathologist afterwards, and it was very clear that the patient could have been told he had cancer but they just didn't know exactly what type it was and they didn't want to get into specifics until they knew that every test had been done. This patient was probably in the hospital close to a week and a half and, every time I would go in the room, he would keep saying to me, I don't have cancer do I? And I was not at liberty to even tell him anything because the staff and the respirologist wouldn't tell him.

Source: Lisa K Hicks, Yulia Lin, David W Robertson, Deborah L Robinson and Sarah I Woodrow, (2001), Understanding the clinical dilemmas that shape medical students' ethical development: questionnaire survey and focus group study, British Medical Journal, 2001;322;709-710

The principle of autonomy of the patient

3. 1. The consent for medical treatment.

3. 2. Capacity of the patient

3. 3. To tell or not to tell the truth to the patient?

3. 4. Voluntariness or the free choice of the patient 3. 5. Substitute decision-making

3. 6. Confidentiality

Consent to medical treatment

Patients are entitled to make decisions about their medical care and to be given relevant information on which to base such decisions. The physician's obligation to obtain the patient's consent to treatment is grounded in the ethical principles of patient autonomy and respect for persons and is affirmed by Canadian law and professional policy. A large body of research supports the view that the process of obtaining consent can improve patient satisfaction and compliance and, ultimately, health outcomes. An exception to the requirement to obtain consent is the emergency treatment of incapable persons, provided there is no reason to believe that the treatment would be contrary to the person's wishes if he or she were capable.

What is consent? Consent is the "autonomous authorization of a medical intervention . . . by individual patients."[1] Patients are entitled to make decisions about their medical care and have the right to be given all available information relevant to such decisions. Obtaining consent is not a discrete event; rather, it is a process that should occur throughout the relationship between clinician and patient.[2] Although the term "consent" implies acceptance of treatment, the concept of consent applies equally to refusal of treatment. Patients have the right to refuse treatment and to be given all available information relevant to the refusal. Consent has three components: disclosure, capacity and voluntariness. "Disclosure" refers to the provision of relevant information by the clinician and its comprehension by the patient. "Capacity" refers to the patient's ability to understand the relevant information and to appreciate those consequences of his or her decision that might reasonably be foreseen. "Voluntariness" refers to the patient's right to come to a decision freely, without force, coercion or manipulation.

Consent may be explicit or implied.[3] Explicit consent can be given orally or in writing. Consent is implied when the patient indicates a willingness to undergo a certain procedure or treatment by his or her behaviour. For example, consent for venipuncture is implied by the action of rolling up one's sleeve and presenting one's arm. For treatments that entail risk or involve more than mild discomfort, explicit rather than implied consent should be obtained. Signed consent forms document but cannot replace the consent process. There are no fixed rules as to when a signed consent form is required. Some hospitals require that a consent form be signed by the patient for surgical procedures but not for certain equally risky interventions. If a signed consent form is not required, and the treatment carries risk, clinicians should seriously consider writing a note in the patient's chart to document that the consent process has occurred.

The notion of consent is grounded in the ethical principles of patient autonomy and respect for persons. "Autonomy" refers to the patient's right to make free decisions about his or her health care. Respect for persons requires that health care professionals refrain from carrying out unwanted interventions and that they foster patients' control over their own lives. Law Obtaining the patient's consent to medical care is a legal requirement. Obtaining valid consent before carrying out medical, therapeutic and diagnostic procedures has long been recognized as an elementary step in fulfilling the doctor's obligations to the patient.[9] Empirical studies Several meta-analyses and reviews have suggested that the process of obtaining consent can be an important component of a successful physician-patient relationship. One review found that effective physician-patient communication improved emotional health, symptom resolution, level of function, results of physiologic measures and pain control.[10] A meta-analysis showed that providing information about what the patient would feel and what would be done in the course of stressful and painful medical procedures consistently reduced negative feelings, pain and distress.[11] Another demonstrated that information-giving by physicians was associated with small to moderate increases in patient satisfaction and compliance with treatment

Obtaining valid consent requires that patients participate in problem solving as much as they wish. Patients should be free to ask questions and receive answers about treatment options not discussed by the clinician. The consent process also requires that patients actively participate in decision making and authorize the decision. Even if the patient is predisposed to follow the clinician's recommendation, the clinician should actively engage the patient in the consent process. A patient's incapacity does not exempt the physician from the requirement to obtain consent. If a patient is mentally incapable of making medical decisions, the clinician must obtain consent from a substitute

The statutory law of some provinces permits nonconsensual treatment in specific circumstances, such as: the involuntary admission of psychiatric patients and the treatment of irresponsible patients with communicable disease. There are other potential exceptions to the requirement to obtain consent. "Therapeutic privilege" refers to the physician's withholding of certain information in the consent process in the belief that disclosure of this information would harm or cause suffering to the patient.[32] "Waiver" refers to a patient's voluntary request to forego one or more elements of disclosure.

Five exceptions to the informed consent requirements: (Veatch, 1997, 203 )

1. 2. 3. 4. Public health emergency Medical emergency The case of an incompetent patient The therapeutic privilege (that allows a physician to withhold information on the basis that to divulge the information would by potentially harmful to a depressed, emotionally drained, or unstable patient. Or disclosure would cause counter therapeutic deterioration in the physical, psychological or emotional condition of the patient. Harmful outcomes include: endangering life, causing irrational decisions, producing anxiety and stress, jeopardizing the success of the treatment, impairing patient decision making) 5. The patient waiver.

Instrument used to measure the decisional capacity of the patient

Mini Mental State Examination right / wrong Orientation Questions: Ask the following questions: [ [ [ [ [ [ [ [ [ [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] 1. What is today's date? ] 2. What is the month? ] 3. What is the year? ] 4. What day of the week is today? ] 5. What season is it? ] 6. What is the name of this clinic (place)? ] 7. What floor are we on? ] 8. What city are we in? ] 9. What county are we in? ] 10. What state are we in? PLACE DATE

IMMEDIATE RECALL: Ask the subject if you may test his/her memory. Then say "ball", "flag", "tree" clearly and slowly, about 1 second for each. After you have said all 3 words, ask him/her to repeat them. The first repetition determines the score (0-3), but keep saying them until he/she can repeat all 3, up to 6 tries. If he/she does not eventually learn all 3, recall cannot be meaningfully tested: [ [ [ ] [ ] [ ] [ ] 11. BALL ] 12. FLAG ] 13. TREE Note # trials: IMMEDIATE RECALL:

ATTENTION A) Ask the subject to begin with 100 and count backwards by 7. Stop after 5 subtractions. Score the correct subtractions. [ [ [ [ [ ] [ ] [ ] [ ] [ ] [ ] 14. "93" ] 15. "86" ] 16. "79" ] 17. "72" ] 18. "65" SERIAL 7's TOTAL:

Ask the subject to spell the word "WORLD" backwards. The score is the number of letters in correct position. For example, "DLROW" is 5, "DLORW" is 3, "LROWD" is 0. [ [ [ [ [ ] [ ] [ ] [ ] [ ] [ ] 19. "D" ] 20. "L" ] 21. "R" ] 22. "O" ] 23. "W" "DLROW" TOTAL: Greater score of A or B:

DELAYED VERBAL RECALL: Ask the subject to recall the 3 words you previously asked him/her to remember. [ [ [ ] [ ] [ ] [ ] 24. BALL? ] 25. FLAG? ] 26. TREE? DELAYED VERBAL RECALL:

NAMING: Show the subject a wrist watch and ask him/her what it is. Repeat for pencil. [ [ ] [ ] [ ] 27. WATCH ] 28. PENCIL

] [

] 29. REPETITION

3-STAGE COMMAND: Give the subject a plain piece of paper and say, "Take the paper in your hand, fold it in half, and put it on the floor." [ [ [ ] [ ] [ ] [ ] 30. TAKES ] 31. FOLDS ] 32. PUTS

READING: Hold up the card reading, "Close your eyes", so the subject can see it clearly. Ask him/her to read it and do what it says. Score correctly only if the subject actually closes his/her eyes. [ ] [ ] 33. CLOSES EYES

WRITING: Give subject a piece of paper and ask him/her to write a sentence. It is to be written spontaneously. It must contain a subject and verb and be sensible. Correct grammar and punctuation are not necessary. [ ] [ ] 34. SENTENCE LANGUAGE:

] [

] 35. HEXAGONS

To calculate MMSE score automatically, click here: TOTAL MMSE (s7s): (MMSE maximum score = 30) 24 - 30 20 - 23 10 - 19 1 - 9 0 normal, depending on age, education, complaints mild moderate severe profound MMSE (dlrow): MMSE (max):

Cut-off score = 10 points

Glasgow Coma Score The GCS is scored between 3 and 15, 3 being the worst, and 15 the best. It is composed of three parameters : Best Eye Response, Best Verbal Response, Best Motor Response, as given below : Best Eye Response. (4) 1. 2. 3. 4. No eye opening. Eye opening to pain. Eye opening to verbal command. Eyes open spontaneously.

Best Verbal Response. (5) 1. 2. 3. 4. 5. No verbal response Incomprehensible sounds. Inappropriate words. Confused Orientated

Best Motor Response. (6) 1. No motor response. 2. Extension to pain. 3. Flexion to pain. 4. Withdrawal from pain. 5. Localising pain. 6. Obeys Commands.

Note that the phrase 'GCS of 11' is essentially meaningless, and it is important to break the figure down into its components, such as E3V3M5 = GCS 11. A Coma Score of 13 or higher correlates with a mild brain injury, 9 to 12 is a moderate injury and 8 or less a severe brain injury.

Cut-off score = 7 points

Disclosure -to tell the truth to the patient

In the context of patient consent, "disclosure" refers to the provision of relevant information by the clinician and its comprehension by the patient. Both elements are necessary for valid consent. Disclosure should inform the patient adequately about the treatment and its expected effects, relevant alternative options and their benefits and risks, and the consequences of declining or delaying treatment. The clinician's goal is to disclose information that a reasonable person in the patient's position would need in order to make an informed decision. Therefore, clinicians may need to consider how the proposed treatment (and other options) might affect the patient's employment, finances, family life and other personal concerns. Clinicians may also need to be sensitive to cultural and religious beliefs that can affect disclosure

"Disclosure," in the context of patient consent, refers to both the provision of relevant information by the clinician and its comprehension by the patient. Both elements are necessary for valid consent. Why is disclosure important? Ethics In keeping with the ethical principles of patient autonomy and respect for persons, disclosure promotes patients' informed and reflective participation in health care decisions. Disclosure also promotes a continuing and trusting relationship between the patient and his or her physician.[1,2] Law Elements of disclosure The necessary elements of disclosure are as follows: a description of the treatment and its expected effects (e.g., duration of hospital stay, expected time to recovery, restrictions on daily activities, scars); information about relevant alternative options and their expected benefits and relevant risks; and an explanation of the consequences of declining or delaying treatment. The patient must be given an opportunity to ask questions, and the clinician must respond to questions or requests for further information.

Exceptions
Waiver "Waiver" refers to a patient's voluntary request to forego one or more elements of disclosure. For example, a patient may not wish to know about a serious prognosis (e.g., cancer) or about the risks of treatment. Because most legislations and common law do not directly address the issue of waiver, clinicians should proceed cautiously when a patient appears to be requesting a waiver. Therapeutic privilege "Therapeutic privilege" refers to the withholding of information by the clinician during the consent process in the belief that disclosure of this information would lead to the harm or suffering of the patient Disclosure is an essential component of valid consent

Empirical studies The results of empirical studies of disclosure suggest that patients' desire for information closely agrees with the legal standard for disclosure. In one study more than 80% of a sample of surgical patients wanted to know about the nature of their illness, the reason for the surgery, the nature of the operation, the expected duration of their stay in hospital, the chances of a successful result, the expected time to return to normal daily activities and any special precautions they would need to take after surgery.[12] Similar observations have been made with regard to patients' desire for information about anesthesia.[13-15]

Studies have indicated that 6% to 18% of patients prefer not to know about the risks of treatment.[12,13,16] However, this research evaluated patients who had already decided to proceed with surgery or had already undergone successful surgery and did not address the question of what they wanted to know about risks in order to consent to surgery. Most studies in this area have found that routine verbal disclosure is not completely effective,[17-25] whereas written[26-30] or combined written and verbal disclosure[31-34] can improve patients' knowledge. Other aids to disclosure, such as bedside decision instruments[35] and interactive videodiscs,[36] are promising but require further evaluation Effective communication is critical to the disclosure process. If the clinician fosters good communication the patient will be encouraged to provide personal information and express his or her values, goals and fears. A full discussion of effective physician-patient communication is beyond the scope of this article, but several relevant reviews are available

During the consent process clinicians should routinely address each element of disclosure, giving information about each of the areas described earlier (see "Elements of disclosure"). The goal is to disclose any information that a reasonable person in the patient's circumstances would want to know. Depending on the treatment in question, clinicians may need to consider how it, and other options, could affect the patient's employment, finances, family life and other personal concerns. Disclosure should also take account of the patient's cultural and religious beliefs. For example, in some cultures a family-centered model of decision making is favored over one centered on the individual Throughout each disclosure session the clinician should invite questions. Encouraging patients to restate information in their own words is one way to ensure that information has been understood. The clinician should document each discussion, noting the patient's questions and how these were answered. Special cultural or religious considerations are particularly important to document.

CONFIDENTIALITY
The physicians duty to keep patient information confidential has been a cornerstone of medical ethics since the time of Hippocrates. The Hippocratic Oath states: What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself holding such things shameful to be spoken about. The Oath, and some more recent versions, allow no exception to this duty of confidentiality. For example, the WMAs International Code of Medical Ethics requires that A physician shall preserve absolute confidentiality on all he knows about his patient even after the patient has died. However, other codes reject this absolutist approach to confidentiality. The possibility that breaches of confidentiality are sometimes justified calls for clarification of the very idea of confidentiality.

The high value that is placed on confidentiality has three sources: autonomy, respect for others and trust. Autonomy relates to confidentiality in that personal information about an individual belongs to him or her and should not be made known to others without his or her consent. When an individual reveals personal information to another, a physician or nurse for example, or when information comes to light through a medical test, those in the know are bound to keep it confidential unless authorized to divulge it by the individual concerned.

Confidentiality is also important because human beings deserve respect. One important way of showing them respect is by preserving their privacy. In the medical setting, privacy is often greatly compromised, but this is all the more reason to prevent further unnecessary intrusions into a persons private life. Since individuals differ regarding their desire for privacy, we cannot assume that everyone wants to be treated as we would want to be. Care must be taken to determine which personal information a patient wants to keep secret and which he or she is willing to have revealed to others

Trust is an essential part of the physician-patient relationship. In order to receive medical care, patients have to reveal personal information to physicians and others who may be total strangers to them---information that they would not want anyone else to know. They must have good reason to trust their caregivers not to divulge this information. The basis of this trust is the ethical and legal standards of confidentiality that healthcare professionals are expected to uphold. Without an understanding that their disclosures will be kept secret, patients may withhold personal information. This can hinder physicians in their efforts to provide effective interventions or to attain certain public health goals.

The WMA Declaration on the Rights of the Patient (Lisbon, 1981, Bali, 1995, Santiago, Chile, 2005) summarizes the patients right to confidentiality as follows: All identifiable information about a patient's health status, medical condition, diagnosis, prognosis and treatment and all other information of a personal kind must be kept confidential, even after death. Exceptionally, the patients relatives may have a right of access to information that would inform them of their health risks. Confidential information can only be disclosed if the patient gives explicit consent or if expressly provided for in the law. Information can be disclosed to other healthcare providers only on a strictly "need to know" basis unless the patient has given explicit consent. All identifiable patient data must be protected. The protection of the data must be appropriate to the manner of its storage. Human substances from which identifiable data can be derived must be likewise protected.

Legal requirements to reveal certain kinds of information without the patients consent are defined in both statutory and common law. The most notable legislated requirement involves the mandatory reporting of patients who suffer from designated diseases, those deemed not fit to drive and those suspected of child abuse. Physicians may disclose confidential information not only when they are required to do so by law but also when there is significant risk of substantial harm to others (which is, in effect, the reasoning underlying any legal duty to warn).

The CMA position statement on AIDS advises physicians that disclosure to a spouse or current sexual partner may not be unethical and, indeed, may be indicated when physicians are confronted with an HIV-infected patient who is unwilling to inform the person at risk. Such disclosure may be justified when all of the following conditions are met: the partner is at risk of infection with HIV and has no other reasonable means of knowing the risk; the patient has refused to inform his or her sexual partner; the patient has refused an offer of assistance by the physician to do so on the patients behalf; and the physician has informed the patient of his or her intention to disclose the information to the partner

The Hippocratic Oath explicitly demands confidentiality in physicians dealings with patients: What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself holding such things shameful to be spoken about. The Hippocratic Oath and subsequent codes of ethics admitted no exceptions to the duty of confidentiality. However, more recent codes allow that breaches of confidentiality may be justified or required in certain circumstances. For example, the CMA Code of Ethics states: Respect the patients right to confidentiality except when this right conflicts with your responsibility to the law, or when the maintenance of confidentiality would result in a significant risk of substantial harm to others or to the patient if the patient is incompetent; in such cases, take all reasonable steps to inform the patient that confidentiality will be breached

Absolute patient confidentiality is superseded by societal priorities or requirements in a few exceptional situations. The requirements are set by provincial statutes and include the following. Recording of vital statistics. Physicians must report cause of death and inform the coroner that a death is accidental or unnatural. Mandatory reporting of communicable diseases. For example, AIDS, but not HIV infection, is reportable in the United States and in Canada. Mandatory reporting of child abuse. This requirement is especially pertinent to emergency-department staff. Mandatory reporting of violent injuries such as gunshot or knife wounds. Mandatory reporting of a patient who poses a danger to himself or herself or to others. Such reporting may have implications under each state or provinces legislation governing motor vehicles. Court subpoena of documents. Physicians are normally required to release documents and records under court orders. However, if the release of records could jeopardize the physicians interest, it is advisable to obtain legal guidance. For example, there may be a conflict between protecting the patients confidentiality and releasing documents under a court order.

Exceptions from the rule of medical confidentiality

. 1. Court subpoena of documents. Physicians are normally required to release documents and records under court orders. 2. Mandatory reporting of communicable diseases. For example, AIDS, gonorrhea, syphilis, etc. 3. Declaration of childs births. If the parents do not declare the birth of their children the doctors, midwifes or nurses must do it. 4. Declaration of deaths: it is one of the obligatory exemptions from the norm of medical confidentiality. Only a doctor can declare a death. 5. Mandatory reporting of child abuse. This requirement is especially pertinent to emergency-department staff. 6. Mandatory reporting of elderly abuse and maltreatment. 7. Reporting of industrial accidents and occupational diseases, etc 8. Maltreatments allowing supposing that a rape, incest or that an indecent assault has been just made. 9. Mandatory reporting of violent injuries such as gunshot or knife wounds. Physicians must report cause of death and inform the coroner that a death is accidental or unnatural. 10. Reporting of impaired drivers (incapable of seeing, hearing deficits or addicted to alcohol or other drugs). Such reporting may have implications under each state or provinces legislation governing motor vehicles. 11. Voluntary abortion by a teenager under age, without the knowledge of their parents. 12. Denunciation of danger of an imminent crime that will be performed (Tarasoff case vs. Regents of the Univ. of California). 13. Reporting of impaired, incompetent colleague physician or healthcare staff or with unethical conduct.

The principle of beneficence

Paternalism in health care
"Paternalism" comes from the Latin pater, meaning to act like a father, or to treat another person like a child. ("Parentalism" is a gender-neutral anagram of "paternalism".) In modern philosophy and jurisprudence, it is to act for the good of another person without that person's consent, as parents do for children. It is controversial because its end is benevolent, and its means coercive. Paternalists advance people's interests (such as life, health, or safety) at the expense of their liberty. In this, paternalists suppose that they can make wiser decisions than the people for whom they act. Paternalist acts may meet the following conditions if X acts paternalistically towards Y by doing (omitting) Z:

1. Z (or its omission ) interferes with the liberty or autonomy of Y. 2. X does so without the consent of Y 3. X does so just because Z will improve the welfare of Y (where this includes
preventing his welfare from diminishing), or in some way promote the interests, values, or good of Y.

Paternalism is the interference with people's liberties or autonomy "for their own good" or to "prevent their harm" irrespective of the preferences of the person whose liberty is being curtailed The difficulty with paternalism for legally competent persons is that, first, someone's sincere belief about what is good for another person may be wrong. With the best intentions people may be mistaken about what harms or benefits others. Weak paternalism honors the autonomous decisions of competent persons while also protecting people who may be acting nonautonomously or on insufficient information. Weak paternalism is especially important in medicine since it extends more protection to people who are impaired by such things as illness, ignorance, drugs, or fear.

Justifiable Paternalism
Paternalism is justifiable if someone lacks the capacity to look after his or her interests. Some form of protection is justified or even obligatory when people cannot make decisions for themselves, suffer incapacitating illnesses, show involuntary self-destructive behavior, or make choices so inappropriate to their own established life goals that we doubt their autonomy. Interference seems justified in the presence of people's nonautonomous, self-destructive behavior or when they resort to acts that are irrational, unreasonable, and uncharacteristic. Thus, paternalism (some prefer the less sexist word "parentalism") is sometimes a duty in medicine, and clinicians have to decide when they should act like good parents and help people who cannot look out for themselves.

Generally, an act (or the omission of an act) can be said to be paternalistic when it is carried out intentionally on behalf of a person other than oneself, against that persons wishes or without consent, with the explicit purpose of doing good for, or avoiding harm to, that person (Beauchamp & Childress) Beauchamp and Childress (2001) make a distinction between weak paternalism and strong paternalism. In weak paternalism, an agent intervenes on grounds of beneficence or nonmaleficence only to prevent substantially nonvoluntary conductthat is, to protect persons against their own substantially nonautonomous action[s] (p. 181). This is commonly the case when persons are deemed to be too uninformed, too depressed, too much under the control of their addiction ( s), or otherwise incapable of making a decision that most adults would judge to be informed and at least minimally reasoned.

Strong paternalism, by contrast, involves interventions intended to benefit a person, despite the fact that the persons risky choices and actions are informed, voluntary, and autonomous (p. 181). The preponderance of the literature indicates that most authors find weak paternalism to be widely justifiable and strong paternalism are more difficult to defend. Beauchamp and Childress (2001) go so far as to say that weak paternalism may really need no defense, as serious objections are rarely raised against it. They go on to outline conditions that justify strong paternalism. 1. A patient is at risk of a significant, preventable harm. 2. The paternalistic action will probably prevent the harm. 3. The projected benefits to the patient of the paternalistic action outweigh its risks to the patient. 4. The least autonomy-restrictive alternative that will secure the benefits and reduce the risks is adopted. (p. 186) They add, We are tempted to add a fifth condition requiring that a paternalistic action not substantially restrict autonomy.

Against paternalism
Historically, beneficent intentions have led to interventions such as forced medication, restraints, incarceration, prolonged bedrest, forced ice baths, electroconvulsive therapy, castration, lobotomy, forced drug withdrawal, isolation, mandated psychotherapy, sterilization, and mandated attendance at religiously based 12step groups, to name but a few. The presumption of diminished autonomy has been imposed on women, enslaved persons, poor persons (especially those who are indigent or homeless), persons of minority races and ethnicities, persons of minority sexual orientations, persons living with disabilities, and persons living with mental illness. Szasz (1994) quoted C. S. Lewis describing the resulting pattern of relations vis--vis paternalistic mental healthcare.

Of all the tyrannies a tyranny sincerely exercised for the good of its victims may be the most oppressive. . . . To be cured against ones will and cured of states which we may not regard as disease is to be put on a level with those who have not yet reached the age of reason or those who never will; to be classed with infants, imbeciles, and domestic animals. . . . For if crime and disease are to be regarded as the same thing, it follows that any state of mind which our masters choose to call disease can be treated as a crime; and compulsorily cured. . . Even if the treatment is painful, even if it is lifelong, even if it is fatal, that will be only a regrettable accident; the intention was purely therapeutic

The principle of non-maleficence

Doctrine of Double Effect
The doctrine (or principle) of double effect is often invoked to explain the permissibility of an action that causes a serious harm, such as the death of a human being, as a side effect of promoting some good end. It is claimed that sometimes it is permissible to cause such a harm as a side effect (or double effect) of bringing about a good result even though it would not be permissible to cause such a harm as a means to bringing about the same good end. This reasoning is summarized with the claim that sometimes it is permissible to bring about as a merely foreseen side effect a harmful event that it would be impermissible to bring about intentionally.

Four conditions for the application of the principle of double effect: 1. The act itself must be morally good or at least indifferent. 2. The agent may not positively will the bad effect but may permit it. If he could attain the good effect without the bad effect he should do so. The bad effect is sometimes said to be indirectly voluntary. 3. The good effect must flow from the action at least as immediately (in the order of causality, though not necessarily in the order of time) as the bad effect. In other words the good effect must be produced directly by the action, not by the bad effect. Otherwise the agent would be using a bad means to a good end, which is never allowed. 4. The good effect must be sufficiently desirable to compensate for the allowing of the bad effect (p. 1021).

The conditions provided by Joseph Mangan include the explicit requirement that the bad effect not be intended: A person may licitly perform an action that he foresees will produce a good effect and a bad effect provided that four conditions are verified at one and the same time: 1. 2. 3. 4. that the action in itself from its very object be good or at least indifferent; that the good effect and not the evil effect be intended; that the good effect be not produced by means of the evil effect; that there be a proportionately grave reason for permitting the evil effect (

End of Life Decision-Making

The principle of double effect is often mentioned in discussions of what is known as palliative care, medical care for patients with terminal illness in need of pain relief. Three assumptions often operate in the background of these discussions: 1. It is assumed that the side effect of hastening death is an inevitable or at least likely result of the administration of opioid drugs in order to relieve pain. 2. It is assumed that the hastening of death is a not unwelcome side effect of providing pain relief in the context of palliative care. 3. It is assumed that it would be impermissible to hasten death intentionally in order to cut short the suffering of a terminally ill patient. When these assumptions are made, double effect seems to provide at least part of a justification for administering drugs to relieve pain.

Exemples of double effect:

A doctor who intends to hasten the death of a terminally ill patient by injecting a large dose of morphine would act impermissibly because he intends to bring about the patient's death. However, a doctor who intended to relieve the patient's pain with that same dose and merely foresaw the hastening of the patient's death would act permissibly. (The mistaken assumption that the use of opioid drugs for pain relief tends to hasten death is discussed below in section 5.) A doctor who believed that abortion was wrong, even in order to save the mother's life, might nevertheless consistently believe that it would be permissible to perform a hysterectomy on a pregnant woman with cancer. In carrying out the hysterectomy, the doctor would aim to save the woman's life while merely foreseeing the death of the fetus. Performing an abortion, by contrast, would involve intending to kill the fetus as a means to saving the mother.

 To kill a person whom you know to be plotting to kill you would be impermissible because it would be a case of intentional killing; however, to strike in self-defense against an aggressor is permissible, even if one foresees that the blow by which one defends oneself will be fatal. It would be wrong to throw someone into the path of a runaway trolley in order to stop it and keep it from hitting five people on the track ahead; that would involve intending harm to the one as a means of saving the five. But it would be permissible to divert a runaway trolley onto a track holding one and away from a track holding five: in that case one foresees the death of the one as a side effect of saving the five but one does not intend it. Sacrificing one's own life in order to save the lives of others can be distinguished from suicide by characterizing the agent's intention: a soldier who throws himself on a live grenade intends to shield others from its blast and merely foresees his own death; by contrast, a person who commits suicide intends to bring his or her own life to an end.

The principle of Justice

QUESTIONS OF RESOURCE ALLOCATION can pose practical and ethical dilemmas for clinicians. In the Aristotelian conception of distributive justice, the unequal allocation of a scarce resource may be justified by morally relevant factors such as need or likelihood of benefit. Even using these criteria, it can be difficult to reconcile completing claims to determine which patients should be given priority. To what extent the physicians fiduciary duty toward a patient should supersede the interests of other patients and society as a whole is also a matter of controversy. Although the courts have been reluctant to become involved in allocation decisions in health care, they expect physicians to show allegiance to their patients regardless of budgetary concerns. The allocation of resources on the basis of clinically irrelevant factors such as religion or sexual orientation is prohibited. Clear, fair and publicly acceptable institutional and professional policies can help to ensure that resource allocation decisions are transparent and defensible.

The clinicians goal is to provide optimal care within the limits imposed by the allocation of resources to health care generally and to the institution, program and specific situation in which an individual patient is treated. The following guidelines may prove helpful in practice. 1. Choose interventions known to be beneficial on the basis of evidence of effectiveness. 2. Minimize the use of marginally beneficial tests or marginally beneficial interventions. 3. Seek the tests or treatments that will accomplish the diagnostic or therapeutic goal for the least cost. 4. Advocate for ones own patients but avoid manipulating the system to gain unfair advantage to them.

5. Resolve conflicting claims for scarce resources justly, on the basis of morally relevant criteria such as need (e.g., the patients risk of death or serious harm could be reduced by the treatment) and benefit (e.g., published evidence of effectiveness), using fair and publicly defensible procedures (ideally, incorporating public input). 6. Inform patients of the impact of cost constraints on care, but do so in a sensitive way. Blaming administrative or governmental systems during discussions with the patient at the point of treatment should be avoided; it undermines care by reducing confidence and increasing anxiety at a time when the patient is most vulnerable. 7. Seek resolution of unacceptable shortages at the level of hospital management (mesoallocation) or government (macroallocation).

Functions of medical codes of ethics

Medical codes of ethics serve three main functions: 1. They serve to reassure the public, to build trust between doctors and their patients. 2. They provide guidelines for the profession to discipline and regulate members 3. They provide a framework on which individual members can formulate their decisions.

Hippocratic Oath Ethical code attributed to the ancient Greek physician Hippocrates, adopted as a guide to conduct by the medical profession throughout the ages and still used in the graduation ceremonies of many medical schools. Although little is known of the life of Hippocrates--or, indeed, if he was the only practitioner of the time using this name--a body of manuscripts, called the Hippocratic Collection (Corpus Hippocraticum), survived until modern times. In addition to containing information on medical matters, the collection embodied a code of principles for the teachers of medicine and for their students.

This code, or a fragment of it, has been handed down in various versions through generations of physicians as the Hippocratic oath. The text of the oath itself is divided into two major sections. The first sets out the obligations of the physician to students of medicine and the duties of pupil to teacher. In the second section the physician pledges to prescribe only beneficial treatments, according to his abilities and judgment; to refrain from causing harm or hurt; and to live an exemplary personal and professional life.

Hippocratic Oath - Traditional text I swear by Apollo the physician, by sculapius, Hygeia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgement, the following Oath. "To consider dear to me as my parents him who taught me this art; to live in common with him and if necessary to share my goods with him; to look upon his children as my own brothers, to teach them this art if they so desire without fee or written promise; to impart to my sons and the sons of the master who taught me and the disciples who have enrolled themselves and have agreed to the rules of the profession, but to these alone the precepts and the instruction. I will prescribe regimens for the good of my patients according to my ability and my judgement and never do harm to anyone.

To please no one will I prescribe a deadly drug nor give advice which may cause his death. Nor will I give a woman a pessary to procure abortion. But I will preserve the purity of my life and my art. I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art. In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves. All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal. If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot."

Maimonides Prayer

(Maimonides, 1135-1204 A.D.)

I begin once more my daily work. Be thou with me, Almighty Father of Mercy, in all my efforts to heal the sick. For without Thee, man is but a helpless creature. Grant that I may be filled with love for my art and for my fellow men. May the thirst for gain and the desire for fame be far from my heart. For these are the enemies of Pity and the Ministers of Hate. Grant that I may be able to devote myself, body and soul to thy children who suffer from pain. Preserve my strength, that I may be able to restore the strength of the rich and the poor, the good and the bad, the friend and the foe. Let me see in the sufferer the man alone. When wiser men teach me, let me be humble to learn, for the mind of man is so puny and the art of healing is so vast. But when fools are ready to advise me or to find fault with me, let me not listen to their folly. Let me be intent upon one thing, O Father of Mercy, to be always merciful to thy suffering children. May there never rise in me the notion that I know enough, but give me the strength and leisure and zeal to enlarge my knowledge. Our work is great and the mind of men presses forward forever. Thou has chosen me in thy grace, to watch over the life and death of thy creatures. I am about to fulfill my duties. Guide me in this immense work so that I may be of avail.

Codes of Medical Ethics Ideas

Hyppocratic Oath.
1. The total respect for masters in medical art (fathers) 2. Free medical education for medical students (brothers). 3. The duty to serve life, use of medical knowledge for serving the health of the patient (principles of beneficence and non-maleficence). 4. Professional honesty of the doctor in relations to his patient. 5. Humanity and moral purity of the doctor in professional life 6. Strict respect of the rule of confidentiality of information given by the patient in health care relationships. 7. The sexual relationship between doctor and patient are strictly forbidden. 8. The prohibition of euthanasia, physician assisted suicide and abortion by the doctor.

Maimonides Prayer
1. Confidence in the progress of medical knowledge 2. The duty of professional knowledge update for the aim of perfecting medical healthcare. 3. To base the relationships with the patient on mutual trust and tolerance. 4. The duty to serve the ill man, without consideration of social status 5. Professional probity, thats mean no trespassing the limits of professional competence. 6. Firm condemnation of quackery or charlatanry. 7. The need for self-control of doctor in his dealings with the patient 8. To repeal the interference of pecuniary motives in the relations of the doctor to his patient.

Masci Ten Commandments

1. 2. 3. 4. 5. The total respect to the patient, regardless of his age. The need to treat the patients regardless of their social condition or status. Total respect for medical profession and toward colleagues. Strict observance of the rule of confidentiality The negative comments about medical recommendation and prescriptions of fellow colleagues in the presence of patients are forbidden. 6. The duty to give emotional support to the patient in every stage of his illness. 7. To do medical care of the patient with love and faith. 8. To not destroy for your patient, even the illusion of healing, and to maintain live his faith and hope. 9. Do not consider your profession as drudgery or a burden. 10. The moral duty of life-long learning in medical sciences.

Thomas Percival. Medical Ethics. (1803)

The English physician, Thomas Percival (1740-1804) in 1803 published his Medical Ethics; or, a Code of Institutes and Precepts Adapted to the Professional Conduct of Physicians and Surgeons. This code, following in the tradition of the Hippocratic Oath was to influence the development of later codes of medical ethics. Indeed, the American Medical Association (AMA) adapted and adopted Percival's code for use by American physicians in 1847. The Percivalian code asserted the moral authority and independence of physicians in service to others, affirmed the profession's responsibility to care for the sick, and emphasized individual honor.

Other major ideas:

Obligations of physicians to the society as well as to the patients. Physicians to conduct themselves in a manner that would enhance public respect for the entire medical profession

Main virtues:
tenderness, steadiness, condescension, and authority.

The AMA Code of Ethics (1847) was adapted from the ethical code of conduct published in 1794 by Thomas Percival. This was the first code to be adopted by a national professional organization. The current AMA code of ethics (2001) has nine articles which is two more than the previous version (1980). These additions stress the responsibility the doctor has to the patient and the support of universal access to medical care. Provisions are also added to the revised Oath regarding a commitment to medical education and a responsibility for the betterment of public health. Other features of the Code are:

dedication, competence, compassion and respect honesty and duty to report fraud or deception respect for the law respect for the rights of patients and colleagues respect for privacy and patient confidentiality continued education, study, and consultation with other professionals freedom of association and environment in the practice of the Art responsibility to make efforts to improve the community

Duties of a dentist
The GDC (General Dental Council of England) requires every dentist to affirm that: As a member of the dental profession I will: 1. Make the care of my patients my first concern, treat every patient politely and considerately, and have respect for patients dignity and privacy. 2. Listen to patients and respect their views and give patients information in a way which they can understand. 3. Respect the rights of patients to be involved fully in decisions about their care. 4. Make sure that my personal beliefs do not prejudice my patients care. 5. Act quickly to protect patients from risks if I have good reason to believe that I or a colleague may not be fit to practice. 6. Keep my professional knowledge and skills up to date and recognize the limits of my professional competence. 7. Be honest and trustworthy and respect and protect confidential information. 8. Never discriminate unfairly against my patients or colleagues and be prepared always to justify my actions to them. 9. Avoid abusing my position as a member of the dental profession and work with colleagues in ways which best serve patients interests. From: General Dental Council (1997) Duties of a Dentist. GDC, London.

The Nuremberg Code (1947) is a set of principles for human experimentation set as a result of the Nuremberg trials at the end of the Second World War. Specifically, they were in response to the inhumane Nazi human experimentation carried out during the war by individuals such as Dr. Josef Mengele. In April of the same year, 1947 Dr. Leo Alexander had submitted to the Counsel for War Crimes six points defining legitimate medical research. The trial verdict adopted these points and added an extra four. The ten points constituted the "Nuremberg Code". Although the legal force of the document was not established and it was not incorporated directly into either the American or German law, the Nuremberg Code and the related Declaration of Helsinki are the basis for the The Nuremberg code includes such principles as informed consent and absence of coercion; properly formulated scientific experimentation; and beneficence towards experiment participants.

The ten points are: 1. The voluntary consent of the human subject is absolutely essential. This means that the person involved should have legal capacity to give consent; should be so situated as to be able to exercise free power of choice, without the intervention of any element of force, fraud, deceit, duress, over-reaching, or other ulterior form of constraint or coercion; and should have sufficient knowledge and comprehension of the elements of the subject matter involved as to enable him to make an understanding and enlightened decision. 2. The experiment should be such as to yield fruitful results for the good of society, unprocurable by other methods or means of study, and not random and unnecessary in nature 3. The experiment should be so designed and based on the results of animal experimentation and a knowledge of the natural history of the disease or other problem under study that the anticipated results will justify the performance of the experiment. 4. The experiment should be so conducted as to avoid all unnecessary physical and mental suffering and injury.

5. No experiment should be conducted where there is an a priori reason to believe that death or disabling injury will occur; except, perhaps, in those experiments where the experimental physicians also serve as subjects. 6. The degree of risk to be taken should never exceed that determined by the humanitarian importance of the problem to be solved by the experiment. 7. Proper preparations should be made and adequate facilities provided to protect the experimental subject against even remote possibilities of injury, disability, or death. 8. The experiment should be conducted only by scientifically qualified persons. The highest degree of skill and care should be required through all stages of the experiment of those who conduct or engage in the experiment. 9. During the course of the experiment the human subject should be at liberty to bring the experiment to an end if he has reached the physical or mental state where continuation of the experiment seems to him to be impossible. 10. During the course of the experiment the scientist in charge must be prepared to terminate the experiment at any stage, if he has probable cause to believe, in the exercise of the good faith, superior skill and careful judgment required of him that a continuation of the experiment is likely to result in injury, disability, or death to the experimental subject.

The ten Nuremberg rules 1. Voluntary informed consent 2. Inaccessible practical results for humanity by other means. 3. The experience should be based on results obtained previously on the animal. 4. Avoid any suffering and any physical or mental damage. 5. Not experience if risk of death or disability unless the doctor serves as a Guinea pig. 6. The risk shall not exceed the positive value of the problem a resolve. 7. Prevent any risk of injury, disability or death. 8. Experiments may be performed only by people of professional competence. 9. The subject must be free to interrupt experience at any time. 10. The scientist should cease if continuation may cause injury, disability or death.

Declaration of Geneva (1948)

a modern form of the Hippocratic Oath
At the Time of Being Admitted as Member of the Medical Profession: I solemnly pledge myself to consecrate my life to the service of humanity. I will give to my teachers the respect and gratitude which is their due. I will practice my profession with conscience and dignity. The health of my patient will be my first consideration. I will respect the secrets which are confided in me. I will maintain by all means in my power, the honor and the noble traditions of the medical profession. My colleagues will be my brothers. I will not permit considerations of religion, nationality, race, party politics, or social standing to intervene between my duty and my patient. I will maintain the utmost respect for human life, from the time of conception; even under threat, I will not use my medical knowledge contrary to the laws of humanity. I make these promises solemnly, free and upon my honor.

THE INTERNATIONAL CODE OF MEDICAL ETHICS

DUTIES OF DOCTORS IN GENERAL

A DOCTOR SHALL always maintain the highest standards of professional conduct. A DOCTOR SHALL not permit motives of profit to influence the free and independent exercise of professional judgment on behalf of patients. A DOCTOR SHALL, in all types of medical practice, be dedicated to providing competent medical service in full technical and moral independence, with compassion and respect for human dignity. A DOCTOR SHALL deal honestly with patients and colleagues, and strive to expose those doctors deficient in character or competence, or who engage in fraud or deception. The following practices are deemed to be unethical conduct :(a) Self-advertising by doctors, unless permitted by the laws of the country and the Code of Ethics of the National Medical Association. (b) Paying or receiving any fee or any other consideration solely to procure the referral of a patient or for prescribing or referring a patient to any source. A DOCTOR SHALL respect the rights of patients, of colleagues, and of other health professionals, and shall safeguard patient confidences. A DOCTOR SHALL act only in the patient's interest when providing medical care which might have the effect of weakening the physical and mental condition of the patient. A DOCTOR SHALL use great caution in divulging discoveries of new techniques or treatment through non-professional channels. A DOCTOR SHALL certify only that which he has personally verified.

DUTIES OF DOCTORS TO THE SICK

A DOCTOR SHALL always bear in mind the obligation of preserving human life. A DOCTOR SHALL owe his patients complete loyalty and all the resources of his science. Whenever an examination or treatment is beyond the doctor's capacity he should summon another doctor who has the necessary ability. A DOCTOR SHALL preserve absolute confidentiality except where others are endangered on all he knows about his patient even after the patient has died (only

in 1968 edition).
A DOCTOR SHALL give emergency care as a humanitarian duty unless he is assured that others are willing and able to give such care.

DUTIES OF DOCTORS TO EACH OTHER

A DOCTOR SHALL behave towards his colleagues as he would have them behave towards him (the Golden Rule, Matthew, 7: 12). A DOCTOR SHALL NOT entice patients from his colleagues. A doctor must observe the principles of The Declaration of Geneva approved by The World Medical Association.

World Medical Association. International code of medical ethics. World Medical Association Bulletin 1949;1(3): 109, 111.

American Medical Association Code of Ethics

I. A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights. II. A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities. III. A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient. IV. A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law. V. A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated. VI. A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care. VII. A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health. VIII. A physician shall, while caring for a patient, regard responsibility to the patient as paramount. IX. A physician shall support access to medical care for all people. Adopted June 1957; revised June 1980; revised June 2001

Code of Ethics of The Canadian Dental Association

Preamble This Code of Ethics is a set of principles of professional conduct to which dentists must aspire to fulfil their duties to their patients, to the public, to the profession, and to their colleagues.

A dentist's foremost responsibility is to the patient. Dentistry is a profession, in part, because the decisions of its members involve moral choices. Every dental practitioner makes decisions that involve choices between conflicting values while providing care for patients. Life and Health: The primary concern is the life and general health of the patient.

Patient Autonomy: The patient has the right to choose, on the basis of adequate information, from alternate treatment plans that meet professional standards of care. The treatment plan chosen by the patient may or may not be that which the dentist would prefer. Aesthetic Values: Oral and facial appearance is important to the self image of the patient and an important consideration of dental practice. Cost: Dentistry often offers treatment choices with a range of costs. Appropriate treatment alternatives are to be presented each with its associated costs and benefits.

Responsibilities to Patients
Article 1: Service As a primary health care provider, a dentist's first responsibility is to the patient. As such, the competent and timely delivery of quality care within the bounds of clinical circumstances presented by the patient, shall be the most important aspect of that responsibility. Article 2: Competency The privilege of dentists to be accorded professional status rests primarily in the knowledge, skill, and experience with which they serve their patients and society. All dentists, therefore, must keep their knowledge of dentistry contemporary, and must provide treatment in accordance with currently accepted professional standards. Article 8: Choice of Treatment A dentist must discuss with the patient treatment recommendations including benefits, prognosis and risks, reasonable alternatives and associated costs to allow the patient to make an informed choice. A dentist shall inform the patient if the proposed oral health care involves treatment techniques or products which are not in general recognized or accepted by the dental profession. Article 9: Confidentiality Patient information acquired in the practice of dentistry, shall be kept in strict confidence except as required by law.

Responsibilities to the Public

Article 1: Representation Dentists should represent themselves in a manner that contributes to the esteem of the profession. Dentists shall not represent their education, qualifications or competence in any way that would be false or misleading. Article 3: Choice of Dentist A dentist shall at all times respect and support the public's right to a free choice of dentist. A dentist must not participate in any plan, scheme or arrangement which might limit or interfere with a person's freedom or ability to choose a dentist. Article 7: Market Advocacy Dentists must not lend their name or provide written testimonial for reward or not, to any product or material offered to the public.

Responsibilities to the Profession

Article 1: Support of the Profession Society provides the profession the privilege of self-regulation. This responsibility is borne and implemented by professional associations and licensing bodies. Therefore, dentists have an obligation to participate in the advancement of the profession, support of its professional organizations and to observe applicable Codes of Ethics. Article 4: Professional Equality The profession should be viewed as a partnership of equals. Although interests and expertise may vary, all dentists are colleagues that have equal moral status and obligation in the decision making process of the activities of the profession. Article 3: Advertising Dentists should build their reputation on their professional ability and integrity. Dentists should participate in health promotion programs that are in the best interest of the public and supported by the profession. Dentists shall conduct any promotional activity in accordance with acceptable professional standards and within applicable legislation.

Responsibilities to Colleagues Article 1: Consultation and Referral When a patient is referred to another dentist for consultation and/or treatment, a dentist, upon completion of the care contemplated in the referrals, shall return the patient to the referring dentist. Article 2: Judgements in Peer Relations A dentist should not make disparaging comments of the procedures or qualifications of a colleague to a patient or the public. In the interest of the public dentists are encouraged to consult with a previous dentist, concerning treatment rendered. Through discussion, it should be possible to advise a patient how to achieve an appropriate resolution

P R I N C I P L E S O F Ethics and C O D E O F Professional Conduct (American Dental Association-2005)

INTRODUCTION The dental profession holds a special position of trust within society. As a consequence, society affords the profession certain privileges that are not available to members of the publicat-large. In return, the profession makes a commitment to society that its members will adhere to high ethical standards of conduct. These standards are embodied in the ADA Principles of Ethics and Code of Professional Conduct (ADA Code). The ADA Code is, in effect, a written expression of the obligations arising from the implied contract between the dental profession and society. Members of the ADA voluntarily agree to abide by the ADA Code as a condition of membership in the Association. They recognize that continued public trust in the dental Profession is based on the commitment of individual dentists to high ethical standards of conduct. The ADA Code has three main components: The Principles of Ethics, the Code of Professional Conduct and the Advisory Opinions. The Principles of Ethics are the aspirational goals of the profession. They provide guidance and offer justification for the Code of Professional Conduct and the Advisory Opinions. There are five fundamental principles that form the foundation of the ADA Code: patient autonomy, nonmaleficence, beneficence, justice and veracity.

I. PATIENT AUTONOMY (self-governance). The dentist has a duty to respect the

patients rights to self-determination and confidentiality. This principle expresses the concept that professionals have a duty to treat the patient according to the patients desires, within the bounds of accepted treatment, and to protect the patients confidentiality. Under this principle, the dentists primary obligations include involving patients in treatment decisions in a meaningful way, with due consideration being given to the patient's needs, desires and abilities, and safeguarding the patients privacy. 1.A. PATIENT INVOLVEMENT. The dentist should inform the patient of the proposed treatment, and any reasonable alternatives, in a manner that allows the patient to become involved in treatment decision
1.B. PATIENT RECORDS. Dentists are obliged to safeguard the confidentiality of patient records. Dentists shall maintain patient records in a manner consistent with the protection of the welfare of the patient. 1.B.2. CONFIDENTIALITY OF PATIENT RECORDS. 1.B.1. FURNISHING COPIES OF RECORDS. A dentist has the ethical obligation on request of either the patient or the patients new dentist to furnish in accordance with applicable law, either gratuitously or for nominal cost, such dental records or copies or summaries of them, including dental X-rays or copies of them, as will be beneficial for the future treatment of that patient.

Section 2 PRINCIPLE: NONMALEFICENCE (do no harm). The dentist has a

duty to refrain from harming the patient. This principle expresses the concept that professionals have a duty to protect the patient from harm. Under this principle, the dentists primary obligations include keeping know-ledge and skills current, knowing ones own limitations and when to refer to a specialist or other professional, and knowing when and under what circumstances delegation of patient care to auxiliaries is appropriate. EDUCATION. The privilege of dentists to be accorded professional status rests primarily in the knowledge, skill and experience with which they serve their patients and society. All dentists, therefore, have the obligation of keeping their knowledge and skill current. 2.B. CONSULTATION AND REFERRAL. Dentists shall be obliged to seek consultation, if possible, whenever the welfare of patients will be safeguarded or advanced by utilizing those who have special skills, knowledge, and experience 2.C. USE OF AUXILIARY PERSONNEL. Dentists shall be obliged to protect the health of their patients by only assigning to qualified auxiliaries those duties which can be legally delegated.

2.F. PATIENT ABANDONMENT. Once a dentist has undertaken a course of treatment, the dentist should not discontinue that treatment without giving the patient adequate notice and the opportunity to obtain the services of another dentist. Care should be taken that the patients oral health is not jeopardized in the process. 2.G. PERSONAL RELATIONSHIPS WITH PATIENTS. Dentists should avoid interpersonal relationships that could impair their professional judgment or risk the possibility of exploiting the confidence placed in them by a patient.

Section 3 PRINCIPLE: BENEFICENCE (do good). The dentist has a duty to

promote the patient's welfare. This principle expresses the concept that professionals have a duty to act for the benefit of others. Under this principle, the dentists primary obligation is service to the patient and the public-at-large. The most important aspect of this obligation is the competent and timely delivery of dental care within the bounds of clinical circumstances presented by the patient, with due consideration being given to the needs, desires and values of the patient. The same ethical considerations apply whether the dentist engages in fee-forservice, managed care or some other practice arrangement. Dentists may choose to enter into contracts governing the provision of care to a group of patients; however, contract obligations do not excuse dentists from their ethical duty to put the patient's welfare first.

3.C. RESEARCH AND DEVELOPMENT. Dentists have the obligation of making the results and benefits of their investigative efforts available to all when they are useful in safeguarding or promoting the health of the public. 3.B. GOVERNMENT OF A PROFESSION. Every profession owes society the responsibility to regulate itself. Such regulation is achieved largely through the influence of the professional societies. 3.A. COMMUNITY SERVICE. Since dentists have an obligation to use their skills, knowledge and experience for the improvement of the dental health of the public and are encouraged to be leaders in their community, dentists in such service shall conduct themselves in such a manner as to maintain or elevate the esteem of the profession.

3.E. ABUSE AND NEGLECT. Dentists shall be obliged to become familiar with the signs of abuse and neglect and to report suspected cases to the proper authorities, consistent with state laws. 3.E.1. REPORTING ABUSE AND NEGLECT. The public and the profession are best served by dentists who are familiar with identifying the signs of abuse and neglect and knowledgeable about the appropriate intervention resources for all populations. Dentists have a concurrent ethical obligation to respect an adult patients right to selfdetermination and confidentiality and to promote the welfare of all patients. Care should be exercised to respect the wishes of an adult patient who asks that a suspected case of abuse and/or neglect not be reported, where such a report is not mandated by law. With the patients permission, other possible solutions may be sought. A dentists ethical obligation to identify and report the signs of abuse and neglect is, at a minimum, to be consistent with a dentists legal obligation in the jurisdiction where the dentist practices. Dentists, therefore, are ethically obliged to identify and report suspected cases of abuse and neglect to the same extent as they are legally obliged to do so in the jurisdiction where they practice.

Section 4 PRINCIPLE: JUSTICE (fairness). The dentist has a duty to treat people
fairly. This principle expresses the concept that professionals have a duty to be fair in their dealings with patients, colleagues and society. Under this principle, the dentist's primary obligations include dealing with people justly and delivering dental care without prejudice. In its broadest sense, this principle expresses the concept that the dental profession should actively seek allies throughout society on specific activities that will help improve access to care for all. 4.A. PATIENT SELECTION. While dentists, in serving the public, may exercise reasonable discretion in selecting Patients for their practices, dentists shall not refuse to accept patients into their practice or deny dental service to patients because of the patients race, creed, color, sex or national origin. 4.B. EMERGENCY SERVICE. Dentists shall be obliged to make reasonable arrangements for the emergency care of their patients of record. Dentists shall be obliged when consulted in an emergency by patients not of record to make reasonable arrangements for emergency care.

Section 5 PRINCIPLE: VERACITY (truthfulness). The dentist has a duty to

communicate truthfully. This principle expresses the concept that professionals have a duty to be honest and trust-worthy in their dealings with people. Under this principle, the dentist's primary obligations include respecting the position of trust inherent in the dentist-patient relationship, communicating truthfully and without deception, and maintaining intellectual integrity. 5.A. REPRESENTATION OF CARE. Dentists shall not represent the care being rendered to their patients in a false or misleading manner. 5.A.2. UNSUBSTANTIATED REPRESENTATIONS. A dentist who represents that dental treatment or diagnostic techniques recommended or performed by the dentist has the capacity to diagnose, cure or alleviate diseases, infections or other conditions, when such represen-tations are not based upon accepted scientific knowledge or research, is acting unethically. 5.B. REPRESENTATION OF FEES. Dentists shall not represent the fees being charged for providing care in a false or misleading manner.

5.B.2. OVERBILLING. It is unethical for a dentist to increase a fee to a patient solely because the patient is covered under a dental benefits plan. 5.B.3. FEE DIFFERENTIAL. Payments accepted by a dentist under a governmentally funded program, a component or constituent dental society sponsored access program, or a participating agreement entered into under a program of a third party* shall not be considered as evidence of overbilling in determining whether a charge to a patient, or to another third party* 5.B.4. TREATMENT DATES. A dentist who submits a claim form to a third party* reporting incorrect treatment dates for the purpose of assisting a patient in obtaining benefits under a dental plan, which benefits would otherwise be disallowed, is engaged in making an unethical, false or misleading representation to such third party.* 5.B.5. DENTAL PROCEDURES. A dentist who incorrectly describes on a third party* claim form a dental procedure in order to receive a greater payment or reimbursement or incorrectly makes a non-covered procedure appear to be a covered procedure on such a claim form is engaged in making an unethical, false or misleading representation to such third party.*

5.B.6. UNNECESSARY SERVICES. A dentist who recommends and performs unnecessary dental services or procedures is engaged in unethical conduct. *A third party is any party to a dental prepayment contract that may collect premiums, assume financial risks, pay claims, and/or provide administrative services. 5.C. DISCLOSURE OF CONFLICT OF INTEREST. A dentist who presents educational or scientific information in an article, seminar or other program shall disclose to the readers or participants any monetary or other special interest the dentist may have with a company whose products are promoted or endorsed in the presentation. Disclosure shall be made in any promotional material and in the presentation itself. 5.D. DEVICES AND THERAPEUTIC METHODS. Except for formal investigative studies, dentists shall be obliged to prescribe, dispense, or promote only those devices, drugs and other agents whose complete formulae are available to the dental profession.

5.D.1. REPORTING ADVERSE REACTIONS. A dentist who suspects the occurrence of an adverse reaction to a drug or dental device has an obligation to communicate that information to the broader medical and dental community, 5.D.2. MARKETING OR SALE OF PRODUCTS OR PROCEDURES. Dentists who, in the regular conduct of their practices, engage in or employ auxiliaries in the marketing or sale of products or procedures to their patients must take care not to exploit the trust inherent in the dentist-patient relationship for their own financial gain. 5.E. PROFESSIONAL ANNOUNCEMENT. In order to properly serve the public, dentists should represent themselves in a manner that contributes to the esteem of the profession. Dentists should not misrepresent their training and competence in any way that would be false or misleading in any material respect

5.F.2. EXAMPLES OF FALSE OR MISLEADING. The following examples are set forth to provide insight into the meaning of the term false or misleading in a material respect. a) contain a material misrepresentation of fact, b) omit a fact necessary to make the statement considered as a whole not materially misleading, c) be intended or be likely to create an unjustified expectation about results the dentist can achieve, and d) contain a material, objective representation, whether express or implied, that the advertised services are superior in quality to those of other dentists, if that representation is not subject to reasonable substantiation. 5.F.3. UNEARNED, NONHEALTH DEGREES. A dentist may use the title Doctor or Dentist, DDS, DMD or any additional earned, advanced academic degrees in health service areas in an announcement to the public. The announcement of an unearned academic degree may be misleading because of the likelihood that it will indicate to the public the attainment of specialty or diplomate status.

Euthanasia
Some definitions. All definitions of euthanasia agree that euthanasia means shortening the patients life usually based on the belief that the patient would be better off dead. Euthanasia is the active, intentional termination of a patients life by a doctor who thinks that death is of benefit to the patient. Voluntary euthanasia is euthanasia at the request (or at least with the consent) of the patient. Involuntary euthanasia is euthanasia carried out against the wishes of a competent person. Non-voluntary euthanasia is euthanasia carried out on incompetent patients such as babies or patients with dementia. Active euthanasia is the intentional taking of a patients life by a doctor who thinks that death is of benefit to the patient. Passive euthanasia is the intentional termination of a patients life by omission, for example by withdrawing treatment. Physician-assisted suicide (PAS) is where a doctor helps the patient to take his or her own life. In the Netherlands, no distinct moral difference is being made between PAS and euthanasia. The practical difference may not be significant there is little difference between a patient taking a lethal medication into his mouth and swallowing it and the doctor placing the lethal medication into the patients mouth and the patient swallowing it.

Euthanasia may be voluntary, involuntary or nonvoluntary, depending on (a) the competence of the recipient, (b) whether or not the act is consistent with his or her wishes (if these are known) and (c) whether or not the recipient is aware that euthanasia is to be performed

Supporters of euthanasia and assisted suicide reject the argument that there is an ethical distinction between these acts and acts of forgoing life-sustaining treatment. They claim, instead, that euthanasia and assisted suicide are consistent with the right of patients to make autonomous choices about the time and manner of their own death. Opponents of euthanasia and assisted suicide claim that death is a predictable consequence of the morally justified withdrawal of life-sustaining treatments only in cases where there is a fatal underlying condition, and that it is the condition, not the action of withdrawing treatment, that causes death. A physician who performs euthanasia or assists in a suicide, on the other hand, has the death of the patient as his or her primary objective.

Although opponents of euthanasia and assisted suicide recognize the importance of self-determination, they argue that individual autonomy has limits and that the right to self-determination should not be given ultimate standing in social policy regarding euthanasia and assisted suicide. Supporters of euthanasia and assisted suicide believe that these acts benefit terminally ill patients by relieving their suffering,16 while opponents argue that the compassionate grounds for endorsing these acts cannot ensure that euthanasia will be limited to people who request it voluntarily. Opponents of euthanasia are also concerned that the acceptance of euthanasia may contribute to an increasingly casual attitude toward private killing in society. Most commentators make no formal ethical distinction between euthanasia and assisted suicide, since in both cases the person performing the euthanasia or assisting the suicide deliberately facilitates the patients death. Concerns have been expressed, however, about the risk of error, coercion or abuse that could arise if physicians become the final agents in voluntary euthanasia. There is also disagreement about whether euthanasia and assisted suicide should rightly be considered medical procedures. Euthanasia and assisted suicide is considered against the will of God by most World religions.

The conditions required for doctors to justify euthanasia in Netherlands:

1. The request for euthanasia must come only from the patient and must be entirely free and voluntary. 2. The patients request must be well-considered, durable and persistent. 3. The patient must be experiencing intolerable (not necessarily physical) suffering, with no prospect for improvement. 4. Euthanasia must be a last resort. Other alternatives to alleviate the patients situation must have been considered and found wanting. 5. Euthanasia must be performed by a physician. 6. The physician must consult with an independent colleague who has experience in this field.

Euthanasia Conditions in Belgium (11)

The new Belgian law (adopted May 2002, took effect on Sept. 2002) defines euthanasia as action on the part of a third person intended to end the life of someone who has requested it. Under this law, committing euthanasia is no longer a criminal offence if several strict conditions are fulfilled: The patient is older than 18 years, legally competent, and conscious at the time of the request. The patient has a serious and incurable condition as a result of which he is suffering constant and unbearable physical or psychological pain which cannot be alleviated with medical or other treatment. The request for euthanasia must be voluntary, carefully considered, repeated, and not the result of any external pressure. Once a request for euthanasia has been made, the physician is obliged to:

 Fully inform the patient about his health status and life expectancy and discuss all possible options with the patient, including palliative care. Agree with the patient that there is no other reasonable option. Ensure that the patient does indeed experience unbearable suffering, and that the request is not transient; discussions must therefore be held repeatedly over a reasonable period of time. Consult another physician about the patient, discussing the incurable and serious nature of the disease process and the unbearable suffering and the request for euthanasia. Discuss the request with other members of the care team, and with the family if this is what the patient wants. The patients request must be written, dated, and signed. If the patient is unable to sign, the request must be written by someone without material benefit in the patients death. The patient may revoke this request at any time.

20 Feb 2008 ... Luxembourg has become the third European country to legalise euthanasia

Differences between euthanasia and physician assisted suicide

In assisted suicide, a qualified medical practitioner supplies the patient with the information, procedures and means (lethal dose of drugs), for taking his or her life but, unlike in the case of voluntary active euthanasia, it is the patient (not the doctor) who act last. To put this another way, in the case of active euthanasia it is the qualified medical practitioner who kill the patient, whereas in the case of assisted suicide the patient kills him or herself. In both of them the ultimate choice rests with the patient, both involve a qualified medical practitioner (oe his proxy, a nurse), and both result in the foreseeable and intended death.

Criteria for a Good Death

1. Natural. There are four modes of death: natural, accident, suicide, and homicide. Any survivor would prefer a loved ones death to be natural. No suicide is a good death. 2. Mature. After age 70. Near the pinnacle of mental functioning but old enough to have experienced and savored life. 3. Expected. Neither sudden nor unexpected Survivors-to-be do not like to be surprised. 4. Honorable. Filled with honorifics but not dwelling on past failures. Death begins an ongoing obituary, a memory in the minds of the survivors. The Latin phrase is: De mortuis nil nisi bonum (Of the dead [speak] nothing but good). 5. Prepared. A living trust, prepaid funeral arrangements. That the decedent had given thought and made for the necessary legalities surrounding death

6. Accepted. Willing the obligatory, that is, accepting the immutables of chance and nature and fate; not raging into the night; acceding to natures unnegotiable demands. 7. Civilized. To have some of your loved ones physically present the That the dying scene be enlivened by fresh flowers, beautiful pictures, and cherished music. 8. Generative. To pass down the wisdom of the tribe to younger generations; to write; to have shared memories and histories; to act like a beneficent sage. 9. Rueful. To cherish the emotional state which is a bittersweet admixture of sadness, yearning, nostalgia, regret, appreciation, and thoughtfulness. To avoid depression, surrender, or collapse; to die with some projects left to be done; by example, to teach the paradigm that no life is completely complete. 10. Peaceable. That the dying scene be filled with amicability and love, that physical pain be controlled as much as competent medical care can provide. Each death must be considered as an ennobling icon of the human race. Source: Shneidman Edwin, (2007), Criteria for a Good Death, Suicide and Life-Threatening Behavior 37(3) : 245-247

Twelve criteria of a good death

In January 2000, the British Medical Journal carried an editorial entitled A good death. An important aim for health services and for us all (Smith). In it, the principles of a good death were set out as follows: 1. To know when death is coming, and to understand what can be expected. 2. To be able to retain control of what happens. 3. To be afforded dignity and privacy. 4. To have control over pain relief and other symptom control. 5. To have choice and control over where death occurs. 6. To have access to information and expertise of whatever kind is necessary. 7. To have access to any spiritual of emotional support required. 8. To have access to hospice care in any location, not only in hospital. 9. To have control over who is present and who shares the end. 10. To be able to issue advance directives which ensure wishes are respected. 11. To have time to say goodbye, and control over other aspects of timing. 12. To be able to leave when it is time to go, and not to have life prolonged pointlessly. Sursa: Smith Richard, (2000), A good death. An important aim for health services and for us all, British Medical Journal ;320:129-130 ( 15 January )

Euthanasia - The Christian view Christians are mostly against euthanasia. The arguments are usually based on the beliefs that life is given by God, and that human beings are made in God's image. Some churches also emphasise the importance of not interfering with the natural process of death. Life is a gift from God Human beings are valuable because they are made in God's image The process of dying is spiritually important, and should not be disrupted Many churches believe that the period just before death is a profoundly spiritual time All human lives are equally valuable Christians believe that the intrinsic dignity and value of human lives means that the value of each human life is identical. They don't think that human dignity and value are measured by mobility, intelligence, or any achievements in life. Pope Says Abortion, Euthanasia Corrupting Society The Pontiff was addressing participants at a meeting to commemorate the fifth anniversary of the release of his 1995 encyclical Evangelium Vitae (The Gospel of Life), which branded abortion and euthanasia as unjustifiable evils.

Against Physician Assisted Suicide (PAS)

1. If we legalize PAS, we will start down the slippery slope to nonvoluntary euthanasia and eventually we will end up with a social policy endorsing involuntary euthanasia. 2. Abuses of the law are likely: a. patients might be pressured by family members or insurance companies to seek PAS
b. vulnerable groups the elderly, minorities and the poor will be more likely to take advantage of PAS, due to discrimination. c. people without insurance will request PAS because they dont see that they have other options. 3. The legalization of PAS will corrupt medicine and its practitioners. 4. Acceptance of PAS will weaken the prohibition on killing. 5. Patients will give up too easily they will abandon hope and kill themselves. 6. Improvements in palliative and terminal care will cease. 7. Citizens will begin to fear hospitals and medical personnel.
Source: Dieterle J.M., (2007), Physician Assisted Suicide: A New Look at the Arguments, Bioethics, Volume 21 Number 3 pp 127139

Kevorkian, Jack (1928- 2011), American physician (anatomopathologist) best known for his zealous advocacy of an individuals right to assisted suicide. Since 1990 Kevorkian has helped around 130 people who were terminally ill or experiencing extreme suffering end their lives

The Thanatron, Jack Kevorkians Death Machine

Jack Kevorkian, the defrocked doc sent to jail after helping people kill themselves, was released today after serving 8 years of his original 1025 year sentence for murder. One of the conditions of parole, naturally enough, is refraining from assisting suicides. Dr. Death, as he is called by some. Thanatron is, essentially, an automated drip hooked up to an intravenous needle, similar to the popular lethal injection method of execution. Starting with a saline solution, the patient triggers an injection of a potent sedative, sodium thiopental, to put themselves to sleep. Shortly therafter, the machine switches to potassium chloride, which stops the heart while the patient is unconscious.

In 1998 Kevorkian deliberately courted legal action against himself, daring authorities to prosecute him and decide the issue. In November 1998 the national television network Columbia Broadcasting System (CBS) aired a videotape that showed Kevorkian giving another man several injections of lethal medication. The tape also showed the man dying as a result of the injections. Kevorkian identified the victim as 52-year-old Thomas Youk, a resident of Michigan who suffered from amyotrophic lateral sclerosis (also known as Lou Gehrigs Disease). In his trial for murder in early 1999, Kevorkian represented himself and dared the jury to convict him and be judged by history. The jury refused to find Kevorkian guilty of first-degree murder, but convicted him of second-degree murder and delivery of a controlled substance in connection with Youks death. Kevorkian was sentenced in 1999 to 10 to 25 years imprisonment. He spent 8 years in prison and was released from prison in June 1 2007

The Death with Dignity Act (Oregon, USA)

Legalizes PAS, but specifically prohibits euthanasia, where a physician or other person directly administers a medication to end another's life. To request a prescription for lethal medications, the Death with Dignity Act requires that a patient must be: 1. An adult (18 years of age or older), 2. A resident of Oregon, 3. Capable (defined as able to make and communicate health care decisions), 4. Diagnosed with a terminal illness that will lead to death within six months. 5. Patients meeting these requirements are eligible to request a prescription for lethal medication from a licensed Oregon physician. To receive a prescription for lethal medication, the following steps must be fulfilled: 6. The patient must make two oral requests to his or her physician, separated by at least 15 days.

7. The patient must provide a written request to his or her physician, signed in the presence of two witnesses. 8. The prescribing physician and a consulting physician must confirm the diagnosis and prognosis. 9. The prescribing physician and a consulting physician must determine whether the patient is capable. 10. If either physician believes the patient's judgment is impaired by a psychiatric or psychological disorder, the patient must be referred for a psychological examination. 11. The prescribing physician must inform the patient of feasible alternatives to assisted suicide including comfort care, hospice care, and pain control. 12. The prescribing physician must request, but may not require, the patient to notify his or her next-of-kin of the prescription request. 13. To comply with the law, physicians must report to the Department of Human Services (DHS) all prescriptions for lethal medications within seven working days of prescribing the medication

Washington Initiative 1000, nov. 2008 The official ballot summary for the measure, slightly amended following a February 2008 court challenge, is, "This measure would permit terminally ill, competent, adult Washington residents medically predicted to die within six months to request and self-administer lethal medication prescribed by a physician. The measure requires two oral and one written request, two physicians to diagnose the patient and determine the patient is competent, a waiting period, and physician verification of an informed patient decision. Physicians, patients and others [6] acting in good faith compliance would have criminal and civil immunity."

Provisions in the law include: 1. The patient must be an adult (18 or over) resident of the state of Washington 2. The patient must be mentally competent, verified by two physicians (or referred to a mental health evaluation) 3. The patient must be terminally ill with less than 6 months to live, verified by two physicians. 4. The patient must make voluntary requests, without coercion, verified by two physicians 5. The patient must be informed of all other options including palliative and hospice care 6. There is a 15 day waiting period between the first oral request and a written request 7. There is a 48 hour waiting period between the written request and the writing of the prescription 8. The written request must be signed by two independent witnesses, at least one of whom is not related to the patient or employed by the health care facility 9. The patient is encouraged to discuss with family (not required because of confidentiality laws) 10. The patient may change their mind at any time and rescind the request

Legalization of euthanasia and PAS

A. Euthanasia
Country 1. The Netherland 2.Belgium 3. Luxembourg Voted 23. nov. 2000 16 mai 2001 Febr. 2008 Applied Apr. 2001 2 sept. 2002 1, Apr. 2009

B. Physician Assisted Suicide

Country 1. Switzerland 2. Oregon USA 3. The Netherlands 4. Washington State, USA 5. Luxembourg Voted 1937 Nov. 1994 23. nov. 2000 5 nov. 2008 Febr. 2008 Applied 1943 27 oct. 1997 Apr. 2001 5 mars 2009 1 Apr. 2009

Suicide rates per 100 000 by country, year and sex (Table) Most recent year available: December 2005
Country 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. ALBANIA ANTIGUA AND BARBUDA ARGENTINA ARMENIA AUSTRALIA AUSTRIA AZERBAIJAN BAHAMAS BAHRAIN BARBADOS BELARUS BELGIUM BELIZE BOSNIA AND HERZEGOVINA BRAZIL BULGARIA CANADA CHILE CHINA (Selected rural & urban areas) CHINA (Hong Kong SAR) COLOMBIA COSTA RICA CROATIA CUBA CZECH REPUBLIC DENMARK DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR ESTONIA Year 03 95 96 03 01 03 02 95 88 95 03 97 95 91 95 03 01 94 99 02 94 95 03 96 03 00 94 95 87 93 02 Males 4.7 0.0 9.9 3.2 20.1 27.1 1.8 2.2 4.9 9.6 63.3 31.2 12.1 20.3 6.6 21.0 18.7 10.2 13.0 20.7 5.5 9.7 31.4 24.5 27.5 20.2 0.0 6.4 0.1 10.4 47.7 Females 3.3 0.0 3.0 0.5 5.3 9.3 0.5 0.0 0.5 3.7 10.3 11.4 0.9 3.3 1.8 7.3 5.2 1.4 14.8 10.2 1.5 2.1 8.4 12.0 6.8 7.2 0.0 3.2 0.0 5.5 9.8

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36.

FINLAND FRANCE GEORGIA GERMANY GREECE GUATEMALA GUYANA HONDURAS HUNGARY ICELAND INDIA IRAN IRELAND ISRAEL ITALY JAMAICA JAPAN JORDAN KAZAKHSTAN KUWAIT KYRGYZSTAN LATVIA LITHUANIA LUXEMBOURG MALTA MAURITIUS MEXICO NETHERLANDS NEW ZEALAND NICARAGUA NORWAY PANAMA PARAGUAY PERU PHILIPPINES POLAND

03 01 01 01 02 84 94 78 03 01 98 91 01 00 01 85 02 79 02 02 03 03 03 03 03 00 95 03 00 94 02 87 94 89 93 02

31.9 26.6 3.4 20.4 4.7 0.9 14.6 0.0 44.9 19.6 12.2 0.3 21.4 9.9 11.1 0.5 35.2 0.0 50.2 2.5 16.1 45.0 74.3 18.5 8.6 18.8 5.4 12.7 19.8 4.7 16.1 5.6 3.4 0.6 2.5 26.6

9.8 9.1 1.1 7.0 1.2 0.1 6.5 0.0 12.0 5.6 9.1 0.1 4.1 2.7 3.3 0.2 12.8 0.0 8.8 1.4 3.2 9.7 13.9 3.5 1.5 5.2 1.0 5.9 4.2 2.2 5.8 1.9 1.2 0.4 1.7 5.0

1. 2. 3. 4. 5. 6. 7. 8. 9.

PORTUGAL PUERTO RICO REPUBLIC OF KOREA REPUBLIC OF MOLDOVA ROMANIA RUSSIAN FEDERATION SAINT KITTS AND NEVIS SAINT LUCIA SAINT VINCENT AND THE GRENADINES

02 92 02 03 02 02 95 88 86 87 87 02 02 03 02 91 92 01 01 85 01 02 03 94 98 02 02 01 90 02 94 90

18.9 16.0 24.7 30.6 23.9 69.3 0.0 9.3 0.0 0.0 9.1 11.4 23.6 45.0 12.6 44.6 16.6 18.9 26.5 0.2 2.9 12.0 9.5 17.4 13.8 46.7 10.8 17.6 16.6 9.3 8.3 10.6

4.9 1.9 11.2 4.8 4.7 11.9 0.0 5.8 0.0 1.8 0.0 7.6 3.6 12.0 3.9 16.8 7.2 8.1 10.6 0.0 2.3 3.8 4.0 5.0 3.5 8.4 3.1 4.1 4.2 3.1 1.9 5.2

10. SAO TOME AND PRINCIPE 11. SEYCHELLES 12. SINGAPORE 13. SLOVAKIA 14. SLOVENIA 15. SPAIN 16. SRI LANKA 17. SURINAME 18. SWEDEN 19. SWITZERLAND 20. SYRIAN ARAB REPUBLIC 21. TAJIKISTAN 22. THAILAND 23. TFYR MACEDONIA 24. TRINIDAD AND TOBAGO 25. TURKMENISTAN 26. UKRAINE 27. UNITED KINGDOM 28. UNITED STATES OF AMERICA 29. URUGUAY 30. UZBEKISTAN 31. VENEZUELA 32. ZIMBABWE

Suicides rates in Europe around 2000

ara RSuic 1. Grecia 4,2 ara RSuic 2. Malta 4,8 20. Danemarca 18,4 3. Portugalia 5,4 21. Luxemburg 19,4 4. Albania 7,1 22. Frana 20 5. Italia 8,4 23. Moldova 20,7 6. Spania 8,7 24. Austria 20,9 7. Marea Britanie 9,2 25. Elveia 22,5 8. Macedonia 10 26. Belgia 24 9. Olanda 11 27. Croaia 24,8 10. Islanda 11,7 28. Finlanda 28,4 11. Germania 14,3 29. Slovenia 33 30. Ucraina 33,8 12. Romnia 14,3 13. Norvegia 14,6 31. Ungaria 36,1 14. Bosnia-Herzegovina 14,8 32. Letonia 36,5 15. Slovacia 15,4 33. Estonia 37,9 16. Suedia 15,9 34. Belarus 41,5 17. Bulgaria 16,4 35. Rusia 43,1 18. Irlanda 16,8 36. Lituania 51,6 19. Republica Ceh 17,5 * Cazuri la 100.000 locuitori Sursa : Organisation Mondiale de la Sant, (2002), Rapport mondial sur la violence et la sant, Genve, pages. 344-350.

CLONING
Cloning refers to a range of techniques directed at asexual reproduction, or copying of cells and organisms, including the possibility of cloning human beings. Both techniques are the subject of vigorous public debate about scientific, social and ethical implications. Cloning: A form of reproduction in which offspring result not from the chance union of egg and sperm (sexual reproduction) but from the deliberate replication of the genetic makeup of another single individual (asexual reproduction). Human cloning: The asexual production of a new human organism that is, at all stages of development, genetically virtually identical to a currently existing or previously existing human being. It would be accomplished by introducing the nuclear material of a human somatic cell (donor) into an oocyte (egg) whose own nucleus has been removed or inactivated, yielding a product that has a human genetic constitution virtually identical to the donor of the somatic cell. (This procedure is known as somatic cell nuclear transfer, or SCNT). We have declined to use the terms reproductive cloning and therapeutic cloning. We have chosen instead to use the following designations:

 Cloning-to-produce-children: Production of a cloned human embryo, formed for the (proximate) purpose of initiating a pregnancy, with the (ultimate) goal of producing a child who will be genetically virtually identical to a currently existing or previously existing individual. Cloning-for-biomedical-research: Production of a cloned human embryo, formed for the (proximate) purpose of using it in research or for extracting its stem cells, with the (ultimate) goals of gaining scientific knowledge of normal and abnormal development and of developing cures for human diseases. Cloned human embryo: (a) A human embryo resulting from the nuclear transfer process (as contrasted with a human embryo arising from the union of egg and sperm). (b) The immediate (and developing) product of the initial act of cloning, accomplished by successful SCNT, whether used subsequently in attempts to produce children or in biomedical research.

 The technique of cloning. The following steps have been used to produce live offspring in the mammalian species that have been successfully cloned. Obtain an egg cell from a female of a mammalian species. Remove its nuclear DNA, to produce an enucleated egg. Insert the nucleus of a donor adult cell into the enucleated egg, to produce a reconstructed egg. Activate the reconstructed egg with chemicals or electric current, to stimulate it to commence cell division. Sustain development of the cloned embryo to a suitable stage in vitro, and then transfer it to the uterus of a female host that has been suitably prepared to receive it. Bring to live birth a cloned animal that is genetically virtually identical (except for the mitochondrial DNA) to the animal that donated the adult cell nucleus. Animal cloning: low success rates, high morbidity. At least seven species of mammals (none of them primates) have been successfully cloned to produce live births. Yet the production of live cloned offspring is rare and the failure rate is high: more than 90 percent of attempts to initiate a clonal pregnancy do not result in successful live birth. Moreover, the live-born cloned animals suffer high rates of deformity and disability, both at birth and later on. Some biologists attribute these failures to errors or incompleteness of epigenetic reprogramming of the somatic cell nucleus.

 Attempts at human cloning. At this writing, it is uncertain whether anyone has attempted cloning-to-produce children (although at least one physician is now claiming to have initiated several active clonal pregnancies, and others are reportedly working on it). We do not know whether a transferred cloned human embryo can progress all the way to live birth. Stem cell research. Human embryonic stem cells have been isolated from embryos (produced by IVF -In Vitro Fertilization) at the blastocyst stage or from the germinal tissue of fetuses. Human adult stem (or multipotent) cells have been isolated from a variety of tissues. Such cell populations can be differentiated in vitro into a number of different cell types, and are currently being studied intensely for their possible uses in regenerative medicine. Most scientists working in the field believe that stem cells (both embryonic and adult) hold great promise as routes toward cures and treatments for many human diseases and disabilities. All stem cell research is at a very early stage, and it is too soon to tell which approaches will prove most useful, and for which diseases.

 The transplant rejection problem. To be effective as long-term treatments, cell transplantation therapies will have to overcome the immune rejection problem. Cells and tissues derived from adult stem cells and returned to the patient from whom they were taken would not be subject (at least in principle) to immune rejection. Stem cells from cloned embryos. Human embryonic stem cell preparations could potentially be produced by using somatic cell nuclear transfer to produce a cloned human embryo, and then taking it apart at the blastocyst stage and isolating stem cells. These stem cells would be genetically virtually identical to cells from the nucleus donor, and thus could potentially be of great value in biomedical research. Very little work of this sort has been done to date in animals, and there are as yet no published reports of cloned human embryos grown to the blastocyst stage. Although the promise of such research is at this time unknown, most researchers believe it will yield very useful and important knowledge, pointing toward new therapies and offering one of several possible routes to circumvent the immune rejection problem. Although some experimental results in animals are indeed encouraging, they also demonstrate some tendency even of cloned stem cells to stimulate an immune response. The fate of embryos used in research. All extractions of stem cells from human embryos, cloned or not, involve the destruction of these embryos.

Cloning-to-produce-children might serve several purposes. It might allow infertile couples or others to have genetically-related children; permit couples at risk of conceiving a child with a genetic disease to avoid having an afflicted child; allow the bearing of a child who could become an ideal transplant donor for a particular patient in need; enable a parent to keep a living connection with a dead or dying child or spouse; or enable individuals or society to try to replicate individuals of great talent or beauty. These purposes have been defended by appeals to the goods of freedom, existence (as opposed to nonexistence), and well-beingall vitally important ideals. A major weakness in these arguments supporting cloning-to produce-children is that they overemphasize the freedom, desires, and control of parents, and pay insufficient attention to the well-being of the cloned child-to-be. The Council holds that, once the child-to-be is carefully considered, these arguments are not sufficient to overcome the powerful case against engaging in cloning-to-produce-children. First, cloning-to-produce-children would violate the principles of the ethics of human research. Given the high rates of morbidity and mortality in the cloning of other mammals, we believe that cloning-to-produce-children would be extremely unsafe, and that attempts to produce a cloned child would be highly unethical. Indeed, our moral analysis of this matter leads us to conclude that this is not, as is sometimes implied, a merely temporary objection, easily removed by the improvement of technique. We offer reasons for believing that the safety risks might be enduring, and offer arguments in support of a strong conclusion: that conducting experiments in an effort to make cloning-toproduce- children less dangerous would itself be an unacceptable violation of the norms of research ethics. There seems to be no ethical way to try to discover whether cloning-to-producechildren can become safe, now or in the future.

If carefully considered, the concerns about safety also begin to reveal the ethical principles that should guide a broader assessment of cloning-to-produce-children: the principles of freedom, equality, and human dignity. To appreciate the broader human significance of cloning-to-produce-children, one needs first to reflect on the meaning of having children; the meaning of asexual, as opposed to sexual, reproduction; the importance of origins and genetic endowment for identity and sense of self; the meaning of exercising greater human control over the processes and products of human reproduction; and the difference between begetting and making. Reflecting on these topics, the Council has identified five categories of concern regarding cloning-toproduce-children. Problems of identity and individuality. Cloned children may experience serious problems of identity both because each will be genetically virtually identical to a human being who has already lived and because the expectations for their lives may be shadowed by constant comparisons to the life of the original. Concerns regarding manufacture. Cloned children would be the first human beings whose entire genetic makeup is selected in advance. They might come to be considered more like products of a designed manufacturing process than gifts whom their parents are prepared to accept as they are. Such an attitude toward children could also contribute to increased commercialization and industrialization of human procreation.

 The prospect of a new eugenics. Cloning, if successful, might serve the ends of privately pursued eugenic enhancement, either by avoiding the genetic defects that may arise when human reproduction is left to chance, or by preserving and perpetuating outstanding genetic traits, including the possibility, someday in the future, of using cloning to perpetuate genetically engineered enhancements. Troubled family relations. By confounding and transgressing the natural boundaries between generations, cloning could strain the social ties between them. Fathers could become twin brothers to their sons; mothers could give birth to their genetic twins; and grandparents would also be the genetic parents of their grandchildren. Genetic relation to only one parent might produce special difficulties for family life. Effects on society. Cloning-to-produce-children would affect not only the direct participants but also the entire society that allows or supports this activity. Even if practiced on a small scale, it could affect the way society looks at children and set a precedent for future nontherapeutic interventions into the human genetic endowment or novel forms of control by one generation over the next. In the absence of wisdom regarding these matters, prudence dictates caution and restraint.

Human cloning a decade after Dolly

In 1997, Ian Wilmut and colleagues from the Roslin Institute in Edinburgh, Scotland published an article in Nature unceremoniously entitled: Viable offspring derived from fetal and adult mammalian cells. This was, of course, the publication that announced the birth of Dolly the cloned sheep. The paper immediately made headlines around the world and stirred international debate. The scientific community hailed it as a major technical advance that could, among other things, facilitate the creation of animals for research, the production of pharmaceuticals and xenotransplantation. Science selected it as the scientific breakthrough of the year. And, with concomitant advances in embryonic stem cell research, speculation began about using somatic cell nuclear transfer, the technique that created Dolly, to engineer human tissue for the purposes of transplantation a technique dubbed therapeutic cloning. But it was the potential social issues that created the biggest stir. The creation of Dolly led to concerns about cloning a human being a thought that reportedly horrified Wilmut.

This concern spurred policy-makers everywhere to action. Indeed, the United Nations (UN) spent 3 years trying to negotiate an international ban on human cloning. Bogged down by differing views on the ethical acceptability of therapeutic cloning, in 2005 the UN General Assembly settled on an ambiguous non-binding Declaration that calls upon countries to prohibit all forms of human cloning that are incompatible with human dignity. In Canada, the Assisted Human Reproduction Act bans all forms of human cloning. Since 1997, there have been many other cloning controversies, including a 2002 human cloning hoax perpetrated by the Canadian cult, the Raelians, and, most recently, fraudulent somatic cell nuclear transfer research in Korea.

Where is cloning today? There is no evidence that anyone has successfully cloned a human, but the hoped for therapeutic breakthroughs have also been slow to emerge. And despite the hype and controversy, somatic cell nuclear transfer remains a relatively marginal research activity. Stil , many researchers remain optimistic about the scientific potential of somatic cell nuclear transfer, including Wilmut. He recently switched his research focus to the cloning of human tissue for research purposes, an activity that remains illegal in Canada

Dolly died in 2003, but the debate about the ethics of cloning continues.

Abortion
The expulsion of a fetus from the uterus before it has reached the stage of viability (in human beings, usually about the 20th week of gestation). An abortion may occur spontaneously, in which case it is also called a miscarriage (q.v.), or it may be brought on purposefully, in which case it is often called an induced abortion. Spontaneous abortions, or miscarriages, occur for many reasons, including disease, trauma, or genetic or biochemical incompatibility of mother and fetus. Occasionally a fetus dies in the uterus but fails to be expelled, a condition termed a missed abortion. A broad social movement for the relaxation or elimination of restrictions on the performance of abortions resulted in the passing of liberalized legislation in several states in the United States during the 1960s. The U.S. Supreme Court ruled in Roe v. Wade (1973) that unduly restrictive state regulation of abortion was unconstitutional, in effect legalizing abortion on demand for women in the first three months of pregnancy.

Opponents of abortion,(pro life movement) or of abortion for any reason other than to save the life of the mother, argue that there is no rational basis for distinguishing the fetus from a newborn infant; each is totally dependent and potentially a member of society, and each possesses a degree of humanity. Proponents of liberalized regulation of abortion (pro choice movement) hold that, at least during its first three or four months, the fetus exhibits few if any human characteristics; that only a woman herself, rather than the state, has the right to manage her pregnancy; and that the alternative to legal, medically supervised abortion is illegal and demonstrably dangerous, if not deadly, abortion. The public debate of the issue has demonstrated the enormous difficulties experienced by political institutions in grappling with the complex and ambiguous ethical problems raised by the question of abortion.

Attitudes Toward Abortion

We are interested in your opinion on the abortion issue. In your opinion should a pregnant woman be able to obtain a legal abortion in each of the following cases listed below. Not at all 1 Slightly 2 Moderately 3 Quite a bit 4 Very much 5 1. if the woman's health is seriously endangered by the pregnancy 2. if there is a strong chance of a serious defect in the baby 3. if she became pregnant as the result of a rape or incest 4. if she is married and does not want any more children 5. if the family has a very low income and cannot afford any more children 6. if she is not married and does not want to marry the man 7. if the woman wants an abortion for any reason

Abortion
Socio-demographic data Age years; Sex M F (please circle as appropriate); Country of origin ; Mothers occupation.. Fathers occupation Religious affiliation .; How many cigarettes had you smoked yesterday .; Frequency of participation to religious activities (please circle as appropriate) Never Two times a year Monthly Many times per month Once in a week Many times per week At every religious activity from my church

Assisted Reproductive Technologies

The first assisted reproductive technology (ART) was 1. noncoital insemination, which may be intrauterine or intravaginal, using sperm either from a donor or from the womans partner. Sperm has been almost exclusively from anonymous donors, as opposed to sperm from known donors, since 1970. 2. Hormonal ovarian stimulation can be used to treat anovulation or may increase the likelihood of conception in idiopathic infertility by increasing the number of mature oocytes. Ovarian stimulation may also accompany intrauterine insemination.

3. With in vitro fertilization (IVF), multiple ova are matured through hormonal stimulation and retrieved by transvaginal ultrasound-guided needle aspiration. Fertilization occurs in the laboratory either by adding sperm to the culture medium or by injecting a single sperm into the ovum (intracytoplasmic sperm injection). Resulting embryos may be transferred to the womans uterus or cryopreserved for future use. In rare cases preimplantation genetic diagnosis may be used for specific genetic disorders. Embryos may be transferred to the woman who produced the ovum (standard IVF), to another infertile woman (embryo donation) or to a woman who is contracted to carry the pregnancy for someone else (a surrogate mother). Embryos may also be donated for research. Future reproductive possibilities include the creation of offspring genetically identical to an existing or deceased person (4. reproductive cloning), and the development of fetuses in mechanical wombs (5. ectogenesis).

Main International Documents on Human Rights

French Declaration of the Rights of Man and Citizen-1789 17 articles The Universal Declaration on Human Rights- 1948 30 articles International Covenant on Civil and Political Rights (ICCPR) December 10, 1966, 53 articles International Covenant on Economic, Social and Cultural Rights (ICESCR)- December 16, 1966- 31 articles

Key Indicators of Freedom

The items used in the Freedom Index above The right to ... 1. travel in own country 2. travel abroad 3. peacefully associate and assemble 4. teach ideas and receive information 5. monitor human-rights violations 6. ethnic language

The freedom from ... 6. forced or child labor 7. compulsory work permits 8. extrajudicial killings of "disappearances" 9. torture or coercion 10. capital punishment 11. unlawful detention 12. compulsory party or organization membership 13. compulsory religion ro state ideology in schools 14. arts control 15. political censorship of press 16. censorship of mail or telephone tapping 17. police searches of home without warrant 18. arbitrary seizure of personal property

The freedom for ... 19. peaceful political opposition 20. multiparty elections by secret and universal ballot 21. political and legal equqality for women 22. social and econimic equality for women 23. social and economic equality for ethnic minorities 24. independent newspapers 25. independent book publishing 26. independent radio and television networks 27. independent courts 28. independent trade unions

The legal right to ... 29. a nationality 30. being conisdered innocent until proven guilty 31. free legal aid when necessary and cousel of own choice 32. open trial 33. a prompt trial The personal right to ... 34. interracial marriage 35. interreligious marriage, or 36. civil marriage 37. equality of sexes during marriage and for divorce proceedings 38. homosexuality between consenting adults 39. practice any religion 40. determine the number of one's children

Country Ranking in 1985

The Top 10 Countries with Highest Freedom Ranking (35-40 points) (38) Sweden (38) Denmark (37) Netherlands (36) Finland (36) New Zeland (36) Austria (35) Norway (35) France (35) West Germany (35) Belgium

Countries with Highest Freedom Ranking in 2007

1. Andorra* 1 1 Free 2. Australia* 1 1 Free 3. Austria* 1 1 Free 4. Belgium* 1 1 Free 5. Canada* 1 1 Free 6. Chile* 1 1 Free 7. Cyprus* 1 1 Free 8. Czech Republic* 1 1 Free 9. Denmark* 1 1 Free 10. Estonia* 1 1 Free 11. Finland* 1 1 Free 12. France* 1 1 Free 13. Germany* 1 1 Free 14. Iceland* 1 1 Free 15. Ireland* 1 1 Free

1. Italy* 1 1 Free Liechtenstein* 1 1 Free Lithuania* 1 1 Free Luxembourg* 1 1 Free Malta* 1 1 Free Netherlands* 1 1 Free New Zealand* 1

2.

3.

4.

5.

6.

7.

1 Free 8. Norway* 1 1 Free 9. Poland* 1 1 Free 10. Slovakia* 1 1 Free 11. Slovenia* 1 1 Free 12. Spain* 1 1 Free 13. Sweden* 1 1 14. Switzerland* Free

1. United Kingdom* 2. United States*

1 1

1 1

Free Free

The 10 Countries with Lowest Freedom Ranking (0-5 points) in 1985 (5) Zaire (5) Pakistan (4) Bulgaria (3) South Africa (3) USSR (2) China (2) Ehtiopia (1) Romania (1) Libya (0) Iraq

Most oppressive Countries in 2007

1. Burma 7 7 Not Free 2. Cuba 7 7 Not Free 3. North Korea 7 7 Not Free 4. Saudi Arabia 7 6 Not Free 5. Sudan 7 7 Not Free 6. Syria 7 6 Not Free 7. Tunisia 7 5 Not Free 8. Turkmenistan 7 7 Not Free 9. Uzbekistan 7 7 Not Free 10. Vietnam 7 5 Not Free 11. Zimbabwe 7 6 Not Free

Methodology
Political Rights and Civil Liberties Ratings The total number of points awarded to the political rights and civil liberties checklists determines the political rights and civil liberties ratings. Each rating of 1 through 7, with 1 representing the highest and 7 the lowest level of freedom, corresponds to a range of total points (see tables 1 and 2). Status of Free, Partly Free, Not Free Each pair of political rights and civil liberties ratings is averaged to determine an overall status of Free, Partly Free, or Not Free. Those whose ratings average 1.0 to 2.5 are considered Free, 3.0 to 5.0 Partly Free, and 5.5 to 7.0 Not Free

Freedom In The World 2008 Checklist Questions And Guidelines Political Rights Checklist
A. Electoral Process 1. Is the head of government or other chief national authority elected through free and fair elections? 2. Are the national legislative representatives elected through free and fair elections? 3. Are the electoral laws and framework fair?

B. Political Pluralism And Participation

1. Do the people have the right to organize in different political parties or other competitive political groupings of their choice, and is the system open to the rise and fall of these competing parties or groupings? 2. Is there a significant opposition vote and a realistic possibility for the opposition to increase its support or gain power through elections? 3. Are the peoples political choices free from domination by the military, foreign powers, totalitarian parties, religious hierarchies, economic oligarchies, or any other powerful group? 4. Do cultural, ethnic, religious, or other minority groups have full political rights and electoral opportunities?

C. Functioning Of Government
1. Do the freely elected head of government and national legislative representatives determine the policies of the government? 2. Is the government free from pervasive corruption? 3. Is the government accountable to the electorate between elections, and does it operate with openness and transparency? B. Is the government or occupying power deliberately changing the ethnic composition of a country or territory so as to destroy a culture or tip the political balance in favor of another group? Additional Discretionary Political Rights Questions: A. For traditional monarchies that have no parties or electoral process, does the system provide for genuine, meaningful consultation with the people, encourage public discussion of policy choices, and allow the right to petition the ruler?

Civil Liberties Checklist

D. Freedom Of Expression And Belief
1. Are there free and independent media and other forms of cultural expression? (Note: In cases where the media are state controlled but offer pluralistic points of view, the survey gives the system credit.) 2. Are religious institutions and communities free to practice their faith and express themselves in public and private? 3. Is there academic freedom, and is the educational system free of extensive political indoctrination? 4. Is there open and free private discussion?

E. Associational and Organizational Rights

1. Is there freedom of assembly, demonstration, and open public discussion? 2. Is there freedom for nongovernmental organizations? (Note: This includes civic organizations, interest groups, foundations, etc.) 3. Are there free trade unions and peasant organizations or equivalents, and is there effective collective bargaining? Are there free professional and other private organizations?

F. Rule of Law
1. Is there an independent judiciary? 2. Does the rule of law prevail in civil and criminal matters? Are police under direct civilian control? 3. Is there protection from political terror, unjustified imprisonment, exile, or torture, whether by groups that support or oppose the system? Is there freedom from war and insurgencies? 4. Do laws, policies, and practices guarantee equal treatment of various segments of the population?

G. Personal Autonomy and Individual Rights

1. Does the state control travel or choice of residence, employment, or institution of higher education? 2. Do citizens have the right to own property and establish private businesses? Is private business activity unduly influenced by government officials, the security forces, political parties/organizations, or organized crime? 3. Are there personal social freedoms, including gender equality, choice of marriage partners, and size of family? 4. Is there equality of opportunity and the absence of economic exploitation?

Key To Scores, Political Rghts And Civil Liberties Ratings, Status Table 1 Table 2 Political Rights (PR) Total scores 36-40 30-35 24-29 18-23 12-17 6-11 0-5 * PR Rating 1 2 3 4 5 6 7 Civil Liberties (CL) Total scores 53-60 44-52 35-43 26-34 17-25 8-16 0-7 CL Rating 1 2 3 4 5 6 7

Table 3 Combined Average of the PR and CL Ratings 1.0 to 2.5 3.0 to 5.0 5.5 to 7.0 Country status Free Partly Free Not Free

Clinical case: A 23 weeks pregnant woman was referred to a tertiary medical centre. She and her partner required the interruption of pregnancy because of a perinatal infection with an estimated 5 to 10% risk of the baby developing a severe multisystem disease with brain involvement. The interruption was carried out. However, as the baby appeared alive, according to the law of the country he was intubated and admitted into the neonatal intensive care unit. The parents said they did not intend to accept this baby, and would never come to see him. The outcome: During the following days, despite full intensive care, the babys condition deteriorated. He developed a severe hyaline membrane disease, seizures due to a bilateral intraventricular haemorrhage, and anuria. Eventually he became comatose. A decision not to resuscitate him was made. The baby died at six days of age. Assignment for the group work: 1. Identify the relevant ethical issues posed by this case. 2. Choose one issue for ethical analysis. 3. Identify the two most relevant options. 4. Identify the pro and con arguments. 5. Assess the arguments and make a choice.

Case I. Ms. Y is 32 years old and has advanced gastric cancer that has resulted in constant severe pain and poorly controlled vomiting. Despite steady increases in her morphine dose, her pain has worsened greatly over the last 2 days. Death is imminent, but the patient pleads incessantly with the hospital staff to put her out of her misery. Case II. Mr. Z is a 39-year-old injection drug user with a history of alcoholism and depression. He presents at an emergency department, insisting that he no longer wishes to live. He repeatedly requests euthanasia on the grounds that he is no longer able to bear his suffering (although he is not in any physical pain). A psychiatrist rules out clinical depression. Tasks: Identify the relevant ethical issues posed by these cases. What principles of bioethics are implied in the two cases? Identify the pro and con arguments.

Solutions
The case of Ms. Y involves a competent, terminally ill patient who is imminently dying and in intractable pain. The case of Mr. Z involves an apparently competent patient who is not dying but is experiencing extreme mental suffering. In both cases the physician is confronted with a request to participate in euthanasia or assisted suicide. The physician should explore the specific reasons behind the request and provide whatever treatment, counselling or comfort measures that may be necessary. For example, for Ms. Y, it may be necessary to seek the advice of a pain specialist about alternative approaches to pain management more difficult, since depression has been ruled out as a contributing factor in the request. The physician must attempt to investigate and ameliorate any other psychosocial problems that are affecting the patient. Providing euthanasia and assisted suicide in either case could result in conviction and imprisonment. However, increasing the morphine dosage for Ms. Y as necessary to relieve her pain is lawful, even though it may eventually prove toxic and precipitate death. and palliation.