Malcolm Parker

Misattributed paternity or ‘false’ paternity is when a man is wrongly thought, by himself and possibly by others, to be the biological father of a child. Nowadays, because of the progression of genetics and genomics the possibility of finding misattributed paternity during familial genetic testing has increased. In contrast to other medical information, which pertains primarily to individuals, information obtained by genetic testing and/or pedigree analysis necessarily has implications for other biologically related members in the family. Disclosing or not a misattributed paternity has a number of different biological and social consequences for the people involved. Such an issue presents important ethical and deontological challenges. The debate centres on whether or not to inform the family and, particularly, whom in the family, about the possibility that misattributed paternity might be discovered incidentally, and whether or not it is the duty of the healthcare professional to disclose the results and to whom. In this paper, we consider the different perspectives and reported problems, and analyse their cultural, ethical and legal dimensions. We compare the position of HCPs from an Italian and British point of view, particularly their role in genetic counselling. We discuss whether the Oviedo Convention of the Council of Europe can be seen as a basis for enriching the debate

Over several decades, ethics and law have been applied to medical education and practice in a way that reflects the continuation during the twentieth century of the strong distinction between facts and values. We explain the development of applied ethics and applied medical law and report selected results that reflect this applied model from an empirical project examining doctors’ decisions on withdrawing/withholding treatment from patients who lack decision-making capacity. The model is critiqued, and an alternative “constitutive” model is supported on the basis that medicine, medical law, and medical ethics exemplify the inevitable entanglement of facts and values. The model requires that ethics and law be taught across the medical education curriculum and integrated with the basic and clinical sciences and that they be perceived as an integral component of medical evidence and practice. Law, in particular, would rank as equal in normative authority to the relevant clinical scientific “facts” of the case, with graduating doctors having as strong a basic command of each category as the other. The normalization of legal knowledge as part of the clinician’s evidence base to be utilized in practice may provide adequate consolation for clinicians who may initially resent further perceived incursions on their traditional independence and discretion.

This paper attempts a partial, critical look at the construction and use of case studies in ethics education. It argues that the authors and users of case studies are often insufficiently aware of the literary nature of these artefacts: this may lead to some confusion between fiction and reality. Issues of the nature of the genre, the fictional, story-constructing aspect of case studies, the nature of authorship, and the purposes and uses of case studies as "texts" are outlined and discussed. The paper concludes with some critical questions that can be applied to the construction and use of case studies in the light of the foregoing analysis

Prenatal Diagnosis (PD) includes diagnostic procedures carried out during the antenatal period, together with Preconception Screening (PS) of prospective parents, and prenatal genetic diagnosis (PGD). The purpose of all these procedures is to provide prospective parents with opportunities to decide whether or not to have a child who will be diseased or disabled. Selection decisions determine what kinds of children are brought into existence; the ability to make these decisions is of huge ethical significance. It raises connected questions about discrimination, the social status of disabled people and the medicalisation of disability; patient vulnerability and the power of the medical and counselling professions to influence decision-making; and the conceptualisation of selection as a public health measure and even as eugenic. In this paper, I outline the ethical issues raised by prenatal diagnosis and describe some of the arguments which have been elaborated in relation to the permissibility of selecting against (and occasionally for) diseases and disabilities. I conclude that there are no good arguments against the prevention of disability through PD but that providing adequate information for decision-making and facilitating uncoerced individual decisions requires further attention.

ObjectiveTo increase knowledge of how doctors perceive futile treatments and scarcity of resources at the end of life. In particular, their perceptions about whether and how resource limitations influence end-of-life decision making. This study builds on previous work that found some doctors include resource limitations in their understanding of the concept of futility.SettingThree tertiary hospitals in metropolitan Brisbane, Australia.DesignQualitative study using in-depth, semistructured, face-to-face interviews. Ninety-six doctors were interviewed in 11 medical specialties. Transcripts of the interviews were analysed using thematic analysis.ResultsDoctors’ perceptions of whether resource limitations were relevant to their practice varied, and doctors were more comfortable with explicit rather than implicit rationing. Several doctors incorporated resource limitations into their definition of futility. For some, availability of resources was one factor of many in assessing futility, secondary to patient considerations, but a few doctors indicated that the concept of futility concealed rationing. Doctors experienced moral distress due to the resource implications of providing futile treatment and the lack of administrative supports for bedside rationing.ConclusionsDoctors’ ability to distinguish between futility and rationing would be enhanced through regulatory support for explicit rationing and strategies to support doctors’ role in rationing at the bedside. Medical policies should address the distinction between resource limitations and futility to promote legitimacy in end-of-life decision making.

The Human Fertilisation and Embryology Authority have recently granted a licence to perform preimplanation genetic diagnosis (PGD) for the homozygous form of familial hypercholesterolaemia (FH), explicitly excluding its use for the heterozygous form. The grounds for such decisions centre on how serious a condition is thought to be as well as on the availability of effective treatment, and decisions are made on a case-by-case basis. The case for licensing homozygous FH is discussed and compared with other cases, and the case for making a distinction between PGD for homozygous and heterozygous FH is also examined. Testing for homozygous FH raises difficult issues of non-disclosure of results for heterozygous FH. Fears that this decision may represent a ‘slippery slope’ to more widespread testing are argued to be overstated

The recently published BMA Guidelines on Withholding and Withdrawing Medical Treatment encourage a balance between deriving maximal benefit from medical treatment, and achieving as natural a death as possible in the circumstances. I argue that the concepts of burdensomeness, natural death and medicalised death are of greater fundamental importance than that of intention, and do not help constitute a moral distinction between withdrawal of treatment and active assistance to die. Nor should they continue to ground the corresponding legal distinction. In the situations of both treatment withdrawal and active assistance to die, disease causation, human agency and moral responsibility are related in the same way. In both situations, we can intend that a person die for the right reasons, based on a concern for natural death.However, the law is reluctant to impose positive obligations on people, in contrast to the protection of negative rights. For example, the Northern Territory’s Rights of the Terminally Ill Act (1996) provided for assisted death as a lawful exception to an otherwise unlawful act, rather than as an enforceable right like the right to refuse unwanted medical treatment. Nevertheless, that the enforceability of a positive right to assisted death is difficult to conceive, is itself the product of a particular historical/moral/religious frame of reference currently under deconstruction. Genuine natural death statutes would consolidate the important principles supported here, and could apply uniform safeguards to all death-hastening decisions.

Debate continues over the acts/omissions doctrine, and over the concepts of duty and charity. Such issues inform the debate over the moral permissibility of euthanasia. Recent papers have emphasised moral sensitivity, medical intuitions, and sub-standard palliative care as some of the factors which should persuade us to regard euthanasia as morally unacceptable. I argue that these lines of argument are conceptually misdirected and have no bearing on the bare permissibility of voluntary euthanasia. Further, some of the familiar slippery slope arguments against voluntary euthanasia compromise the principle of autonomy to which both supporters and opponents of euthanasia adhere. I discuss a model for doctor/patient relationships which can be applied to cases which would be seen by all disputants as strong prima facie cases for euthanasia. I argue that in certain cases it will be ordinary medical practitioners who are duty-bound to assist death

Orr and Siegler have recently defended a restrictive view concerning posthumous sperm retrieval and conception, which would limit insemination to those cases where the deceased man has provided explicit consent for such a procedure. The restrictive view dominates current law and practice. A permissible view, in contrast, would allow insemination and conception in all but those cases where the posthumous procedure has been explicitly refused, or where there is no reasonable evidence that the deceased person desired children. I describe a phenomenology of procreative desires which supports the permissible view, and which is compatible with requirements concerning the interests of the decedent, concepts of medical infertility, and the welfare of the future child. The account illustrates how our current obsession with individual rights and autonomy can be self-defeating and repressive

Julian Savulescu argues for two principles of reproductive ethics: reproductive autonomy and procreative beneficence, where the principle of procreative beneficence is conceptualised in terms of a duty to have the child, of the possible children that could be had, who will have the best opportunity of the best life. Were it to be accepted, this principle would have significant implications for the ethics of reproductive choice and, in particular, for the use of prenatal testing and other reproductive technologies for the avoidance of disability, and for enhancement. In this paper, it is argued that this principle should be rejected, and it is concluded that while potential parents do have important obligations in relation to the foreseeable lives of their future children, these obligations are not best captured in terms of a duty to have the child with the best opportunity of the best life

Autonomy has been the central principle underpinning changes which have affected the practice of medicine in recent years. Medical education is undergoing changes as well, many of which are underpinned, at least implicitly, by increasing concern for autonomy. Some universities have embarked on graduate courses which utilize problem-based learning (PBL) techniques to teach all areas, including medical ethics. I argue that PBL is a desirable method for teaching and learning in medical ethics. It is desirable because the nature of ethical enquiry is highly compatible with the learning processes which characterize PBL. But it is also desirable because it should help keep open the question of what autonomy really is, and how it should operate within the sphere of medical practice and medical education

The development of human genetics raises a wide range of important ethical questions for us all. The interpersonal dimension of genetic information in particular means that genetics also poses important challenges to the idea of patient-centredness and autonomy in medicine. How ought practical ethical decisions about the new genetics be made given that we appear, moreover, no longer to be able to appeal to unquestioned traditions and widely shared communitarian values? This paper argues that any coherent ethical approach to these questions must be able both to uphold the moral status of the individual and at the same time recognise the communitarian, interpersonal dimensions both of the world in which we live and of personal autonomy itself. The paper then goes on to propose an approach to the resolution of the ethical questions raised by the use of the new genetics in reproductive choice through the development of a coherent and principled process of public reason and justification oriented towards the support and development of personal autonomy

The internet is becoming increasingly important in health care practice. The number of health-related web sites is rising exponentially as people seek health-related information and services to supplement traditional sources, such as their local doctor, friends, or family. The development of e-medicine poses important ethical challenges, both for health professionals and for those who provide clinical ethics support for them. This paper describes some of these challenges and explores some of the ways in which those who provide clinical ethics support might respond creatively to them. By offering ways of responding to such challenges, both electronically and face-to-face, the providers of clinical ethics support can show themselves to be an indispensable part of good quality health care provision

Clinical geneticists are increasingly confronted with ethical tensions between their responsibilities to individual patients and to other family members. This paper considers the ethical implications of a “familial” conception of the clinical genetics role. It argues that dogmatic adherence to either the familial or to the individualistic conception of clinical genetics has the potential to lead to significant harms and to fail to take important obligations seriously.Geneticists are likely to continue to be required to make moral judgments in the resolution of such tensions and may find it useful to have access to ethics training and support

Objectives To determine the role played by law in medical specialists9 decision-making about withholding and withdrawing life-sustaining treatment from adults who lack capacity, and the extent to which legal knowledge affects whether law is followed. Design Cross-sectional postal survey of medical specialists. Setting The two largest Australian states by population. Participants 649 medical specialists from seven specialties most likely to be involved in end-of-life decision-making in the acute setting. Main outcome measures Compliance with law and the impact of legal knowledge on compliance. Results 649 medical specialists (of 2104 potential participants) completed the survey (response rate 31%). Responses to a hypothetical scenario found a potential low rate of legal compliance, 32% (95% CI 28% to 36%). Knowledge of the law and legal compliance were associated: within compliers, 86% (95% CI 83% to 91%) had specific knowledge of the relevant aspect of the law, compared with 60% (95% CI 55% to 65%) within non-compliers. However, the reasons medical specialists gave for making decisions did not vary according to legal knowledge. Conclusions Medical specialists prioritise patient-related clinical factors over law when confronted with a scenario where legal compliance is inconsistent with what they believe is clinically indicated. Although legally knowledgeable specialists were more likely to comply with the law, compliance in the scenario was not motivated by an intention to follow law. Ethical considerations (which are different from, but often align with, law) are suggested as a more important influence in clinical decision-making. More education and training of doctors is needed to demonstrate the role, relevance and utility of law in end-of-life care.

SenilityCalled from pleasuresI go tap-tapping down an old man’s backdown the skin of eighty summers wastingon a rib-ladder closingon a history of heart and lungs.These narrowly contracting bags I find, proclaim“Today his chest is clear as yours or mine.”This is the news requiredas the tide of vigilancelaps his sheets each surfacing dawn.“He’s doing very well.”He leans his gaze to the voice dintingthe routine of his roombut slides the focal point towards infinitypast those gatheredto the motes of memoryto wherepinned in the windthrough their age and bondher sacrificial flags go flutteringbattered and fastened into the room’s cornerhinged haggard to his unhinging.In this too a workless son and centrelessclock-bound slaveto the incontinent brain and its seepage.Two tight-wire walkerswell talked out by nine each bed-wet daythe backyard hoist their prayer-wheel creaking.The sheets flap up the scent of their detentions.Time in its time will track them round their modest cornernovice at the f

Plural democratic societies encourage and require the tolerance of disparate views. However, in relation to contentious areas like assisted reproductive technologies and destructive embryo research, tolerance is strained by the normative force of our fundamental beliefs about the moral status of early human forms. Yet in the continuing debates, spokespersons for different positions often do not concede all the implications of their arguments, may sidestep the real moral issues, and can fail to be clear about the foundations on which their arguments and policy advice ultimately rely. Guidelines and statutes can be rendered incoherent by the desire to balance and satisfy opposing values, rather than honestly reflecting the primary values they espouse.I call for greater clarity and honesty as these issues continue to be debated. An uncritical adherence to pluralism will encourage strategic obfuscation, but citizens of democracies need to be clearly informed about all the premises of opposing positions. Decisions about ethically and legally acceptable reproductive technologies ultimately depend on support for one metaphysical grounding at the expense of another. This should be acknowledged, as should its implications for policy.

The Australian Health Ethics Committee’s National Statement on Ethical Conduct in Research Involving Humans (1999) expanded the health and medical focus of preceding statements by including all disciplines of research. The Statement purports to promote a uniformly high ethical standard for this expanded range of research, and is endorsed by, inter alia, the Australian Academy of the Humanities, the Australian Academy of Science, and the Academy of Social Sciences in Australia.High ethical standards should apply to all research involving humans. However, uniformity in the review processes of disparate research endeavours is not a necessary condition for uniformly high ethical standards. Bringing the ethical review of all research under a model which has developed within the context of health and medical research ethics for over thirty years may be inappropriate and at times incoherent. The language, methods, nature and products of research in areas such as the Humanities are often very different from those of health, medical and other sciences.The Behavioural and Social Sciences Ethics Review Committee at The University of Queensland (UQ) had, since the mid-1980s, considered that the guidelines of the time did, in fact, cover all aspects of human experimentation. We describe the ways in which this position was implemented, how issues raised by the new wording in the National Statement have been recently managed by UQ’s research ethics committees, and point to outstanding questions.

A crescendo of panting to her stiff-lunged yearspressed in on her for three days and a bit before the succumbingno word could be wedged between gasps.A knife twist in her life’s two year tail two years’witness to others’ ministerings at her flesh-raw chestturned outward to the airenforced fluency in the language of lint.From nests of treason in her breastat night the insurgency pushed outinto the bloodlinesoutriders of a black hostthe dreadful propaganda of cellsbridgeheads locked down in bone and braina Reichstag fire flowering in her backherstory crumblingmidnight dominoes along her spine.At the endat the panting postin the room curtained for deathher body spat and crackled with a foreign fevereven past the last breath and her eyes drying.In the bare room a malignant hum.When they came for her a thin smoke hung

An Anonymous DeathThe comet, a white haired traveller, hauls its tail behind, thereby hangs its tale. Its particulate history swings away into black time as it skirts you.A million times a million fissions, fires in Andromeda, a surge of ice across a steppe, the moon’s impacted skin. Events escape their birth and move out at the roar of light, hurtling endlessly nowhere and everywhere colliding stray worlds, spinning and groping.At night through cat’s eye domes watchmen on the world’s clearest ranges trap the begetting of suns or discern an ancient death when intercepted at the glass when Diplodocus started the journey into strata or when a hairy thing tottered erect and stretched out tool-seeking fingers. The watchers in the domes live half in a past older than the sun.I tended a white haired man and cry out for a lens to map him. His deeds curve short of my time sputting out in a brown river carrying a wiry oarsman in a sepia photograph. The deeds of friends are buried in a beach wir

Stewart and DeMarco’s economic theory of patient decision-making applied to the case of diabetes is flawed by clinical inaccuracies and an unrealistic depiction of patients as rational traders. The theory incorrectly represents patients’ struggles to optimize their management as calculated trade-offs against the costs of care, and gives an unrealistic, inflexible account of such costs. It imputes to physicians the view that their patients’ lack of compliance is unreasonable, but physicians are accustomed to the variety of human factors which contribute to suboptimal compliance, and work with patients to minimize their influence. By depicting patients as rational traders rather than human beings with a range of motivations and burdens, the economic theory distorts the proper function of informed consent.

Lennard Davis’s Biocultural Critique of the alleged certainty of diagnosis (Davis Journal of Bioethical Inquiry 7:227−235, 2010) makes errors of fact concerning psychiatric diagnostic categories, misunderstands the role of power in the therapeutic relationship, and provides an unsubstantiated and vague alternative to the management of psychological distress via a conceptually outdated model of the relationships between physical and psychological disease and illness. This response demonstrates that diagnostic knowledge vouchsafes legitimate power to physicians, and via them relief to patients who suffer from psychological distress. The history of medicine and psychiatry demonstrates that psychiatric diagnosis shares many features with physical diagnosis, while there is also reason to believe that the two types will continue to be distinct in some respects. Diagnostic categories in psychological medicine, like those in physical medicine, are provisional, probabilistic, and often uncertain. These features do not detract from the dependence on diagnosis of therapeutic efficacy in both domains