Medical ethics enjoyed a remarkable degree of continuity from the days of Hippocrates until its long-standing traditions began to be supplanted, or at least supplemented, around the middle of the twentieth century. Scientific, technological, and social developments during that time produced rapid changes in the biological sciences and in health care. These developments challenged many prevalent conceptions of the moral obligations of health professionals and society in meeting the needs of the sick and injured .The Anglo-American textbook of Beauchamp and (...) Childress became the referential work for the discipline of `bio-ethics'. The authors are convinced that a long history of ancient, medieval and modern health care reflection remains very disappointing from the perspective of contemporary biomedical ethics: “It shows how inadequately, and with what measure of insularity, problems of truthfulness, privacy, justice, communal responsibility and the like were framed in past centuries ”. They defend the four principles approach to biomedical ethics, an approach which somewhat disparagingly has been called principlism.The influence of their work has been so strong that bio-ethics seemed to become overwhelmed by the importance of their contribution. It even created a large separation between Anglo-American approaches in bio-ethics and the European-Continental approach . In any case, contemporary biomedical ethics incorporates theoretical conflicts of considerable complexity, and the diverse theories make it no easier.The personalist approach to biomedical ethics presents itself as a typical European reaction to the rapid changes in medicine and health care. Some call it, however, a kind of renewal of the old Thomistic approach, whereby the concept of `nature' has been replaced by the more dynamic concept of `person'. In that way personalism has been situated by many observers as a `person' centred natural law tradition which focuses on the rational nature of the human person as the moral norm of nature. This gives the impression that personalism is only a very `static' variant of the natural law approach.I would, however, defend the opinion that personalism offers a very dynamic and creative approach to the complexities of recent developments in biomedicine. In what follows, I will illustrate this by clarifying two basic dimensions of the integration of personalism in biomedical ethics: the personalist approach offers a relational foundation for medicine as a healing profession and it presents an ethical framework for the integration of new developments in medicine. First, however, I would like to situate the importance of this theoretical reflection for medical ethics. (shrink)

Advance directives are propagated as instruments to maintain patients’ autonomy in case they can no longer decide for themselves. It has been never been examined whether patients’ and healthy persons themselves are inclined to adhere to these documents. Patients’ and healthy persons’ views on whether instructions laid down in advance directives should be followed because that is (or is not) “the right thing to do”, not because one is legally obliged to do so, were studied and compared with that of (...) medical staff. Method: Vignette study presenting five cases. Cancer patients, healthy persons, nursing staff and physicians (n = 100 in each group) were interviewed. An adherence score was calculated (maximum value 5). The adherence score is found to be low in all groups, yet lowest in patients (1.55; standard deviation 1.13) and healthy controls (1.60; 1.37). The scores are significantly different between nursing staff on the one hand and patients and healthy controls on the other (p < 0.005 and p < 0.05, respectively), and between doctors and patients (p < 0.05). Interviewees who want these documents to be followed tend to live alone and to have already written an advance directive. Conclusions: Cancer patients and healthy persons widely disregard instructions laid down in advance directives and consider them less binding than physicians and nursing staff do. Only a minority tends to adhere more to advance directives. To improve decision-making at the end of life when patients are no longer able to decide for themselves alternative concepts, such as advanced care planning, should be considered. (shrink)

In September 1998 the Bundesrztekammer, i.e., the German Medical Association, published new principles concerning terminal medical care. Even before publication, a draft of these principles was very controversial, and prompted intense public debate in the mass media. Despite some of the critics' suspicions that the principles prepared the way for liberalization of active euthanasia, euthanasia is unequivocally rejected in the principles. Physician-assisted suicide is considered to violate professional medical rules. In leaving aside some of the notions customarily used in the (...) euthanasia debate, e.g., passive euthanasia, the principles emphasize the obligation of physicians to offer and the right of patients to receive palliative care. The principles explicitly list modalities of basic treatment that are indispensable in all cases, such as the obligation to satisfy hunger and thirst. This statement is meant to resolve the dispute on nutrition and hydration at the end of life, as it shifts the focus of care from maintaining physiological parameters to satisfying subjective needs. For patients in a persistent vegetative state, artificial feeding is held to be obligatory. Yet, the principles make reference to recent German jurisdiction which permit the stopping of artificial feeding if it is in accordance with the patient's presumed will. Additionally, the wording concerning this issue is found to remain unclear. Patients' autonomy is strengthened by explicitly welcoming advance directives as a means to ascertain patients' wills. The principles mark some changes compared to earlier documents. They deserve careful analysis and should be considered in the international debate on issues concerning the end of life. (shrink)

Background: Due to recent legislations on euthanasia and its current practice in the Netherlands and Belgium, issues of end-of-life medicine have become very vital in many European countries. In 2002, the Ethics Working Group of the German Association for Palliative Medicine (DGP) has conducted a survey among its physician members in order to evaluate their attitudes towards different end-of-life medical practices, such as euthanasia (EUT), physician-assisted suicide (PAS), and terminal sedation (TS). Methods: An anonymous questionnaire was sent to the 411 (...) DGP physicians, consisting of 14 multiple choice questions on positions that might be adopted in different hypothetical scenarios on situations of “intolerable suffering” in end-of-life care. For the sake of clarification, several definitions and legal judgements of different terms used in the German debate on premature termination of life were included. For statistical analysis t-tests and Pearson-correlations were used. Results: The response rate was 61% (n=251). The proportions of the respondents who were opposed to legalizing different forms of premature termination of life were: 90% opposed to EUT, 75% to PAS, 94% to PAS for psychiatric patients. Terminal sedation was accepted by 94% of the members. The main decisional bases drawn on for the answers were personal ethical values, professional experience with palliative care, knowledge of alternative approaches, knowledge of ethical guidelines and of the national legal frame. Conclusions: In sharp contrast to similar surveys conducted in other countries, only a minority of 9.6% of the DGP physicians supported the legalization of EUT. The misuse of medical knowledge for inhumane killing in the Nazi period did not play a relevant role for the respondents’ negative attitude towards EUT. Palliative care needs to be stronger established and promoted within the German health care system in order to improve the quality of end-of-life situations which subsequently is expected to lead to decreasing requests for EUT by terminally ill patients. (shrink)

The strength of a slippery slope argument is a matter of some dispute. Some see it as a reasonable argument pointing out what probably or inevitably follows from adopting some practice, others see it as essentially a fallacious argument. However, there seems to be a tendency emerging to say that in many cases, the argument is not actually fallacious, although it may be unsubstantiated. I shall not try to settle this general discussion, but merely seek to assess the strength of (...) the slippery slope argument applied to human gene therapy. The structure of my argument will be the following. First, I shall distinguish between three different versions of the slippery slope argument; two logical versions and an empirical one. Next, I will address human gene therapy in terms of each of the three versions, partly relying on slippery slope arguments against this practice that have already surfaced in the literature. I shall argue that neither version pulls through. The logical versions fail primarily because relevant distinctions can be made between different uses of gene therapy, contrary to what the proponents of the arguments claim. The empirical version fails because there seems to be no evidence supporting the claim that we shall in fact slide down the slope if we engage in gene therapy, and because if we accepted the conclusion that we should not allow gene therapy on the basis of the empirical argument, we should have to make very far-reaching and undesirable modifications in health care in general, in order to be consistent. Or at least so I shall argue. (shrink)

Der Beitrag befasst sich mit den Chancen und Risiken einer allfälligen gesetzlichen Legalisierung der Suizidbeihilfe. Die Argumente, die gegen eine solche Legalisierung sprechen, werden zu drei thematischen Gruppen zusammengefasst und erörtert: „Slippery-Slope“-Argumente, Argumente vom „moralischen Druck“, und die Furcht vor einer „Entsolidarisierung der Gesellschaft“ sowie die „Gefährdung des Arzt-Patient-Verhältnisses“. Diese Gegenargumente erweisen sich als nicht zwingend, sofern Kriterien und Richtlinien für eine legitime Form der Suizidbeihilfe entwickelt und staatlich kontrolliert werden könnten.

In pursuit of the dream that patients' exercise of autonomy could extend beyond their span of competence, living wills have passed from controversy to conventional wisdom, to widely promoted policy. But the policy has not produced results, and should be abandoned.

Some doctors do enter into sexual relationships with patients. These relationships can be damaging to the patient involved. One response available to both individual doctors and to disciplinary bodies is to prohibit sexual contact between doctors and patients ("zero tolerance"). This paper considers five ways of arguing for a zero tolerance policy. The first rests on an empirical claim that such contact is almost always harmful to the patient involved. The second is based on a "principles" approach while the third (...) originates in "virtues" ethics. The fourth argues that zero tolerance is an "a priori" truth. These four attempt to establish that the behaviour is always wrong and ought, therefore, to be prohibited. The fifth argument is counterfactual. It claims a policy that allowed sexual contact would have unacceptable consequences. Given the responsibility of regulatory bodies to protect the public, zero tolerance is a natural policy to develop. (shrink)

"When a country legalizes active euthanasia, it puts itself on a slippery slope from where it may well go further downward." If true, this is a forceful argument in the battle of those who try to prevent euthanasia from becoming legal. The force of any slippery slope argument, however, is by definition limited by its reference to future developments which cannot empirically be sustained. Experience in the Netherlands—where a law regulating active euthanasia was accepted in April 2001—may shed light on (...) the strengths as well as the weaknesses of the slippery slope argument in the context of the euthanasia debate. This paper consists of three parts. First, it clarifies the Dutch legislation on euthanasia and explains the cultural context in which it originated. Second, it looks at the argument of the slippery slope. A logical and an empirical version are distinguished, and the latter, though philosophically less interesting, proves to be most relevant in the discussion on euthanasia. Thirdly, it addresses the question whether Dutch experiences in the process of legalizing euthanasia justify the fear of a slippery slope. The conclusion is that Dutch experiences justify some caution. (shrink)

A Christian ethicist discusses such problems as organ transplants, caring for the terminally ill, and defining death.