C O N T E N T S

Preface xi

CHAPTER 1 GENERAL INTRODUCTION

THE NATURE OF BIOMEDICAL ETHICS

RECENTLY DOMINANT

ETHICAL THEORIES 4

The Critical Assessment of Competing Ethical Theories Teleological Versus Deontological Theories 6 Act-Utilitarianism 7 Rule-Utilitarianism 13 Kantian Deontology 18 W. D. Ross's Theory of Prima Facie Duties

THE PRINCIPLES OF BIOMEDICAL ETHICS

ALTERNATIVE DIRECTIONS AND METHODS

Virtue Ethics 28 The Ethics of Care and Feminist Ethics 31 Casuistry: Case-Based Reasoning in Historical Context 34 Reflective Equilibrium and Appeals to Coherence 36

RELEVANT CONCEPTS AND PRINCIPLES 38

Autonomy 39 Liberty-Limiting Principles 44 Paternalism 46

NOTES

ANNOTATED BIBLIOGRAPHY S 3

APPENDIX: SELECTED REFERENCE SOURCES I N

BIOMEDICAL ETHICS S4

CHAPTER 2 THE PHYSICIAN-PATIENT RELATIONSHIP

PHYSICIANS' OBLIGATIONS AND VIRTUES 66

The Hippocratic Oath 66 Council of Ethical and Judicial Affairs, American Medical Association,

Fundamental Elements of the Patient-Physician Relationship 67 Edrnund D. Pellegrino, The Virtuous Physician and the Ethics of

Medicine 68

PHYSICIAN-PATIENT MODELS AND PATIENT AUTONOMY 7 1

James E Childress and Mark Siegler, Metaphors and Models of Doctor-Patient Relationships: Their Implications for Autonomy 7 1

Terrence F. Ackerman, Why Doctors Should Intervene 80

TRUTH TELLING 85

Mack Lipkin, On Lying to Patients 85 Roger Higgs, On Telling Patients the Truth 87

INFORMED CONSENT 93

Judge Spotswood W. Robinson 111, Opinion in Canterbury v. Spence 93 President's Commission for the Study of Ethical Problems in Medicine and

Biomedical and Behavioral Research, The Values Underlying Informed Consent 97

Howard Brody, Transparency: Infonned Consent in Primary Care 103

DETERMINATIONS OF COMPETENCE 1 0 9

Allen E. Buchanan and Dan W. Brock, Standards of Competence 109 Tom Tomlinson, Who Decides, and What? 114

THE PRACTICE OF MEDICINE I N A MULTICULTURAL

SOCIETY 1 1 7

Ruth Macklin, Ethical Relativism in a Multicultural Society Kenneth Kipnis, Quality Care and the Wounds of Diversity

CONFLICTS OF INTEREST AND MANAGED CARE 1 3 0

Edmund D. Pellegrino, Altruism, Self-Interest, and Medical Ethics Marcia Angell, The Doctor as Double Agent 132 Daniel Callahan, Managed Care and the Goals of Medicine 136 E. Haavi Morreim, Revenue Streams and Clinical Discretion 141

ANNOTATED BIBLIOGRAPHY

CHAPTER 3 HOSPITALS, NURSES, FAMILIES, AND MEDICAL CONFIDENTIALITY 1 SO

PROFESSIONAL STATEMENTS 1 5 7

American Hospital Association, A Patient's Bill of Rights American Nurses 'Association Code for Nurses 159

THE ROLE AND RESPONSIBILITIES OF NURSES 1 6 1

Joy Kroeger-Mappes, Ethical Dilemmas for Nurses: Physicians' Orders Versus Patients' Rights 161

Lisa H. Newton, In Defense of the Traditional Nurse 168 Helga Kuhse, Advocacy or Subservience for the Sake of Patients? Amy M. Haddad, The Nurse/Physician Relationship and Ethical

Decision Making 183

THE ROLE OF THE FAMILY 1 8 7

John Hardwig, The Problem of Proxies with Interests of Their Own: Toward a Better Theory of Pmxy Decisions 187

Baruch A. Brody, Hardwig on Proxy Decision Making 196 Thomas A. Mappes and Jane S. Zembaty, Patient Choices, Family Interests,

and Physician Obligations 198

CONFIDENTIALITY 208

Justice Mathew 0. Tobriner, Majority Opinion in Tarasoff v. Regents of the University of California 208

CONTENTS VII

Justice William P. Clark, Dissenting Opinion in Tarasoff v. Regents of the University of California 212

Please Don't Tell!: A Case About HIV and Confidentiality (with commentaries by Leonard Fleck and Marcia Angell) 216

Mark Siegler, Confidentiality in Medicine-A Decrepit Concept 219

ANNOTATED BIBLIOGRAPHY

CHAPTER 4 HUMAN AND ANIMAL RESEARCH

ETHICAL CODES 233

The Nurenaberg Code 233 World Medical Association, Declaration of Helsinki 234 Council for International Organizations of Medical Sciences, International

Guiding Principles for Biomedical Research Involving Animals 237

HISTORICAL AND CULTURAL CAUSES FOR CONCERN 238

Donald F. Phillips, Past Radiation Experiments May h a d to New Efforts for Informed Consent 238

Patricia A. King, The Dangers of Difference 243 Alexander Morgan Capron, Ethical and Human-Rights Issues in Research

on Mental Disorders That May Affect Decision-Making Capacity 247

EXPERIMENTAL DESIGN AND CLINICAL TRIALS I N DEVELOPING COUNTRIES 253

Samuel Hellman and Deborah S. Hellman, Of Mice but Not Men: Problems of the Randomized Clinical Trial 253

Benjamin Freedman, Equipoise and the Ethics of Clinical Research 259 Marcia Angell, The Ethics of Clinical Research in the Third World 265 Harold Varmus and David Satcher, Ethical Complexities of Conducting

Research in Developing Countries 269

ANIMAL RESEARCH 273

Peter Singer, All Animals Are Equal 273 Carl Cohen, The Case for the Use of Animals in Biomedical Research 281 Edwin Converse Hettinger, The Responsible Use of Animals in Biomedical

Research 287 Bernard E. Rollin, Some Ethical Concerns in Animal Research:

Where Do We Go Next? 294

ANNOTATED BIBLIOGRAPHY 296

CHAPTER 5 DEATH AND DECISIONS REGARDING LIFE-SUSTAINING TREATMENT 299

THE DEFINITION AND DETERMINATION OF DEATH 307

President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Why "Update" Death? 307

Charles M. Culver and Bernard Gert, The Definition and Criterion of Death 310

Martin Benjamin, Pragmatism and the Determination of Death 316 Louise Lears, Obtaining Organs from Non-Heart-Beating Cadavers 325

COMPETENT ADULTS AND THE REFUSAL OF LIFE-SUSTAININQ TREATMENT 327

Council on Ethical and Judicial Affairs, American Medical Association, Withholding and Withdrawing LLife-Sustaining Treatment 327

Tia Powell and Bruce Lowenstein, Refusing Life-Sustaining Treatment After Catastrophic Injury: Ethical Implications 330

DNR ORDERS AND MEDICAL FUTILITY 335

Tom Tomlinson and Howard Brody, Ethics and Communication in Do-Not- Resuscitate Orders 335

Mark R. Wicclair, Medical Futility: A Conceptual and Ethical Analysis 340

Howard Brody, The Physician's Role in Determining Futility

ADVANCE DIRECTIVES AND TREATMENT DECISIONS FOR

INCOMPETENT ADULTS 350

Dan W. Brock, Surrogate Decision Making for Incompetent Adults: An Ethical Framework 350

Thomas A. Mappes, Some Reflections on Advance Directives 356 Norman L. Cantor, My Annotated Living Will 363

THE TREATMENT OF IMPAIRED INFANTS 369

John A. Robertson, Involuntary Euthanasia of Defective Newborns 369 Members of The Hastings Center Research Project on the Care of Imperiled

Newborns, Standards of Judgment for Treatment of Imperiled Newborns 365

ANNOTATED BIBLIOGRAPHY

CHAPTER 6 SUICIDE, PHYSICIAN-ASSISTED SUICIDE, AND ACTIVE EUTHANASIA 38 1

THE MORALITY OF SUICIDE 388

Immanuel Kant, Suicide 388 R. B. Brandt, The Morality and Rationality of Suicide

THE MORALITY OF ACTIVE EUTHANASIA 398

James Rachels, Active and Passive Euthanasia 398 Daniel Callahan, Killing and Allowing to Die 402 Dan W. Brock, Voluntary Active Euthanasia 405

THE SUPREME COURT, PHYSICIAN-ASSISTED SUICIDE,

AND TERMINAL SEDATION 407

Chief Justice William H. Rehnquist, Opinion of the Court in Washington v. Glucksberg 407

Chief Justice William H. Rehnquist, Opinion of the Court in Vacco v. Quill 413

Justice Sandra Day O'Connor, Concurring Opinion in Washington v. Glucksberg and Vacco v. Quill 416

David Orentlicher, The Supreme Court and Physician-Assisted Suicide: Rejecting Assisted Suicide but Embracing Euthanasia 41 7

PHYSICIAN-ASSISTED SUICIDE, ACTIVE EUTHANASIA, AND SOCIAL

POLICY 42 1

Timothy E. Quill, Christine K. Cassel, and Diane E. Meier, Care of the Hopelessly Ill: Proposed Clinical Criteria for Physician-Assisted Suicide 42 1

Franklin G. Miller, Timothy E. Quill, Howard Brody, John C. Fletcher, Lawrence 0. Gostin, and Diane E. Meier, Regulating Physician-Assisted Death 424

John D. Arras, On the Slippery Slope in the Empire State: The New York State Task Force on Physician-Assisted Death 430

James L. Bernat, Bernard Gert, and R. Peter Mogielnicki, Patient Refusal of Hydration and Nutrition: An Alternative to Physician-Assisted Suicide or Voluntary Active Euthanasia 436

ANNOTATED BIBLIOGRAPHY

CHAPTER 7 ABORTION AND MATERNAL-FETAL CONFLICTS

THE MORALITY OF ABORTION 484

Pope John Paul 11, The Unspeakable Crime of Abortion 454 Mary Anne Warren, On the Moral and Legal Status of Abortion 456 Don Marquis, Why Abortion Is Immoral 463 Judith Jarvis Thomson, A Defense of Abortion 467 Daniel Callahan, Abortion Decisions: Personal Moralify

ABORTION AND SOCIAL POLICY 478

Justice Harry Blackrnun, Majority Opinion in Roe v. Wade 478 Justices Sandra Day O'Connor, Anthony M. Kennedy, and David H. Souter,

Opinion in Planned Parenthood of Southeastern Pennsylvania v. Casey, Governor of Pennsylvania 482

Susan Sherwin, The Politics of Abortion 488

MATERNAL-FETAL CONFLICTS 490

Thomas H. Murray, Moral Obligations to the Not-Yet Born: The Fetus as Patient 490

Rosemarie Tong, Blessed are the Peacemakers: Commentary on Making Peace in Gestational Conflicts 500

ANNOTATED BIBLIOGRAPHY 504

CHAPTER 8 GENETICS AND HUMAN REPRODUCTION

REPRODUCTIVE RISK, PRENATAL DIAGNOSIS, AND SELECTIVE ABORTION 5 1 6

Leon R. Kass, Implications of Prenatal Diagnosis for the Human Right to Life 516

Laura M. Purdy, Genetics and Reproductive Risk: Can Having Children Be Immoral? 520

REPRODUCTIVE TECHNOLOGIES 527

The New York State Task Force on Life and the Law, Ethical Debates About Infertility and Its Treatment 527

Peter Singer, Creating Embryos 534 Susan Sherwin, Feminist Ethics and In Vitro Fertilization 54 1

GAMETE DONATION AND SURROGACY 546

Thomas H. Murray, Families, the Marketplace, and Values: New Ways of Making Babies 546

Bonnie Steinbock, Surrogate Motherhood as Prenatal Adoption 553 Barbara Katz Rothman, Motherhood: Beyond Patriarchy 557

HUMAN CLONING S 6 1 Leon R. Kass, Cloning of Human Beings 56 1 National Bioethics Advisory Commission, Cloning Human Beings: Executive

Summary 564 Daniel Callahan, Cloning: Then and Now 568 Robert Wachbroit, Genetic Encores: The Ethics of Human Cloning

GENETIC ENGINEERING 577

LeRoy Walters and Julie Gage Palmer, Germ-Line Gene Therapy W. French Anderson, Genetics and Human Malleability 584 Jonathan Glover, What Sort of People Should There Be? 588

ANNOTATED BIBLIOGRAPHY 59s

CHAPTER 9 SOCIAL JUSTICE AND HEALTH-CARE POLICY

JUSTICE, RIGHTS, AND SOCIETAL OBLIGATIONS 610

Allen Buchanan, Justice: A Philosophical Review 610 Kai Nielsen, Autonomy, Equality and a Just Health Care System

RATIONING 627

Daniel Callahan, Aging and the Ends of Medicine 627 Norman Daniels, Is the Oregon Rationing Plan Fair? 634 Daniel Wikler, Ethics and Rationing: "Whether;" "How," or

"How Much"? 64 1

MANAGEDCARE 6SO

Kate T. Christensen, Ethically Important Distinctions Among Managed Care Organizations 650

Allen Buchanan, Managed Care: Rationing Without Justice, but Not Unjustly 65 8

INTERNATIONAL MODELS AND PERSPECTIVES 666

Pat Armstrong, Managing Care the Canadian Way 666 Gerd Richter, The Gennan Health Care System 669 Nicholas Mays and Justin Keen, Will the Fudge on Equity Sustain the NHS into

the Next Millennium? 673

ANNOTATED BIBLIOGRAPHY 678

Appendix: Case Studies

About the Contributors