Reidar Lie

It is a remarkable fact about the development of medical ethics from the 1960s until today that there has been a dramatic shift from a position where it was taken for granted that the physician knows best, to a position where much greater emphasis is put on the patient’s treatment preferences. This shift is evident with regard to physician attitudes towards disclosing a cancer diagnosis. For example, in 1961, a survey of cancer physicians showed that almost 90% of the physicians reported that their usual policy was not to tell their patients that they had cancer . The survey was repeated in 1979, and it showed a complete reversal in attitudes over this 20-year period. 90% reported that their usual policy was to tell their patients that they had cancer .One common way of justifying the new approach is to claim that patients have a right to make their own treatment decisions, referring to the basic value of patient autonomy. However, it is immediately obvious that physicians should not respect all choices made by patients. Consider the following case: A thirty-eight-year-old man with mild upper respiratory infection suddenly developed severe headache, stiff neck, and high fever. He went to an emergency room for help. The diagnosis was pneumococcal meningitis, a bacterial meningitis almost always fatal if not treated. If treatment is delayed, permanent neurological damage is likely. A physician told the patient that urgent treatment was needed to save his life and forestall brain damage. The patient refused to consent to treatment saying he wanted to be allowed to die .Very few, if any, physicians would respect this person’s treatment choice. The reason is that this patient is not competent to make his own decisions. Respect for autonomy only requires that the choices of patients who are competent to make their own decisions are honoured. Judgements about which patients are competent to make their own decisions therefore become crucial

Questions have been raised over the acceptability of conducting human challenge studies in low and middle income countries. Most of these concerns are based on theoretical considerations and there exists little data on the attitudes of stakeholders in these countries. This study examines the view of researchers and REC members in Thailand regarding the design and conduct of challenge studies in the country. A questionnaire was developed based on ethical frameworks for human challenge studies. The target respondents included those who had experience with health-related research at universities, non-university hospitals, and research institutes. A total of 240 respondents completed the on-line survey. In general, the respondents felt that the ethical issues raised by human challenge studies in LMICS do not differ significantly from those in high income countries, including: scientific rationale, safety, appropriate risks, and robust informed consent process. In contrast, issues that have been described as important for human challenge studies in LMICs were rated as having lower importance, including: a publicly available rationale, national priority, and community engagement. Responses did not vary significantly between researchers in different fields, nor between researchers and REC members. These findings provide an important perspective for assessing existing frameworks for human challenges studies in LMICs.

The WHO Consultative Group on Equity and Universal Health Coverage published a comprehensive report titled “Making Fair Choices on the Path to Universal Health Coverage” detailing strategies that countries should adopt when moving towards providing healthcare coverage to the entire population. The report provides detailed guidelines on how to expand coverage to more people, what services should be covered, and how to prioritize these healthcare resources in achieving universal healthcare coverage. The main goal of this WHO report is to ensure fair and equitable access for all population groups within a country during the implementation of UHC. In principle, the group’s approach is sound and fair, but we argue that each country must take into account its own unique situations in designing a pathway towards UHC. China has achieved near UHC but did so by an approach that would have been deemed completely unacceptable based on this group’s recommendations. In this article, we provide a brief review of the Chinese healthcare system and argue that the implementation of the recommendations in the report is not always feasible. We argue that there are alternate pathways towards achieving UHC and there are good reasons for China’s departure from the approach outlined by the WHO report. Nevertheless, we acknowledge substantial inequities still exist for various segments of the population and among the diverse areas of China in accessing healthcare services and make suggestions on how to reduce such inequities within the system.

Obligations of global justice rest mainly on the global rich but also to a lesser extent on the global poor. The governments of poor countries are obliged to fulfill requirements of non-aggression, good governance and decency, along with all other requirements which facilitate the achievement of global justice. So far, obligations of poor countries seem to be taken as given yet the behavior of governments in poor countries and occurrences therein attest to the contrary;this suggests a need to mainstream these obligations in discussions about global justice. If poor countries do not live up to these requirements obstacles arise to the realization of global justice; and they act unjustly in relation to citizens of rich countries which provide them with aid. Uganda is taken as a case in point.

In 2005 Japan completed its first census after the Personal Information Protection Law went into force in April 2005. The debate about the new law raised privacy concerns for the first time among the public. The news-media also provided several examples of possible lack of safeguards in the data collection of sensitive personal information required for the census. The result was the highest non-response rate ever for the Japanese census. Consequently, its accuracy and role as a source for the reliable national statistics for health/welfare policy-making is now critically threatened. In this paper we argue the necessity to adopt specific safeguards to protect personal data in any future census if the trend of increasing non-response rates is to be reversed. We provide some suggestions for such safeguards, and criticize the Japanese government’s response of focusing exclusively on the mechanism of data collection as a means of meeting the privacy challenge

This dissertation is an attempt to develop a model of rational theory change which can be used to elucidate the shift in theories which occurred in cardiology during the 1920s. I examine in detail the introduction of the coronary theory of angina pectoris, and the introduction of the disease entity acute myocardial infarction. With regard to angina pectoris, I argue that the chief rival to the coronary theory, an aortic theory proposed by such investigators as Allbutt and Wenchebach, was not refuted by the available experimental evidence during the 1920s. There were certain facts which this theory could explain, and which the coronary theory today can still not explain. This episode therefore exemplifies what has become known as Kuhn-loss. I make a similar claim with regard to acute myocardial infarction. ;Based on this case study I examine some recent theories of theory change, such as those of Lakatos and Laudan. I criticize these theories both because of certain inherent weaknesses, and because they cannot adequately account for the rationality of this particular episode in the history of cardiology. Then I develop my own account of theory change, based on recent work by Philip Kitcher. I introduce a notion of a 'scientific practice'. Scientific change can be analysed in terms of changes in, and interactions between, the various components of a scientific practice. In particular, I argue that a theory should be regarded as a pattern of reasoning which can be used to give the same general answer to many particular questions. If we examine the relationship between successive theories conceptualised in this way, we will be able to argue for the rationality of scientific change even in cases of Kuhn-loss. I indicate how this particular way of structuring a scientific field enables us to see both the strengths and weaknesses of current cardiology. ;I also examine a second case study: the development in the understanding of surgical shock during the first two decades of this century. I show how this case study can be illuminated by the model of theory change introduced here