State Educational Establishment of Higher Professional

Education «Kursk State Medical University»

Federal Agency of Public Health and Social Development

E.G. Grebenshchikova

BIOETHICS
LECTURE SUMMARIES
For the foreign students of medical universities in Russia

Kursk - 2011
 Grebenshchikova E.G. Bioethics. Lecture summaries. - Kursk: KSMU, 2011. -
136 p.

Reviewers:
Doct. of Philosophy, prof. A.A. Batalov (Ural Med. Academy)
Ass. Prof. B.P. Buravkov (Voronezh Med. Academy)

The manual for English-speaking students of the different countries training in

medical high schools of Russia. The material of the manual is intended to help the
students revise the lecture material, read up for seminar classes, for independent work
in the course of Bioethics. It contains the plan and the abstract of each theme, lists of
the used literature, and also approximate themes of the tests. In manual are presented
basic sections of the course of Bioethics according with the current State educational
standard in given discipline.
The introduction is prepared by Prof. Y.D. Lyashev; the theme « AIDS: Moral
and Social Aspects » — Ass. Prof. E.B. Zykina; the theme «The Principles of Ethics
in Psychiatry» — Ass. Prof. D.P. Kuznetsov.

© E.G. Grebenshchikova, 2011

© KSMU, 2011

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 Государственное образовательное учреждение
высшего профессионального образования
«Курский государственный медицинский университет
Федерального агентства по здравоохранению
и социальному развитию»

Е.Г. Гребенщикова

БИОЭТИКА
КОНСПЕКТ ЛЕКЦИЙ
Учебное пособие для иностранных студентов
медицинских университетов, обучающихся в России

Курск – 2011

3
УДК 614.253 (075) Печатается по решению
ББК 87.75 я73 редакционно-издательского

Г 79 совета ГОУ ВПО КГМУ

Росздрава

Гребенщикова Е.Г. Биоэтика. Конспект лекций. — Курск: ГОУ ВПО

КГМУ Росздрава, 2011. - 136 с.

Рекомендуется Учебно-методическим объединением по медицинскому и

фармацевтическому образованию вузов России в качестве учебного пособия для
иностранных студентов медицинских вузов, обучающихся на английском языке
(Гриф УМО 884 от 29.11.2007).

Рецензенты:
докт. филос. н., проф. А.А. Баталов (Уральская мед. академия)
доц. Б.П. Буравков (Воронежская мед. академия)

Учебное пособие для англоязычных студентов разных стран,

обучающихся в медицинских вузах России. Материал пособия предназначен в
помощь студентам для повторения лекционного материала, подготовки к
семинарским занятиям, для самостоятельной работы по курсу биоэтики.
Содержит план и конспект каждой темы, списки используемой литературы, а
также приблизительную тематику контрольных работ. В нем представлены
основные разделы курса биоэтики в соответствии с действующим
Государственным образовательным стандартом по данной дисциплине.
Предисловие подготовлено проф. Ю.Д. Ляшевым; тема «AIDS: Moral and
Social Aspects» — доц. Е.Б. Зыкиной; тема «The Principles of Ethics in
Psychiatry» — доц. Д.П. Кузнецовым.

ISBN 978-5-7487-1243-9 ББК 87.75я73

 Е.Г. Гребенщикова, КГМУ, 2011
 ГОУ ВПО КГМУ РОСЗДРАВА, 2011

4
 Introduction
Traditionally our society set high moral standards upon the medical
community, recognizing the medical trade as one of the most humane and noble.
Values and norms of medical morals have always been the integral element of
training of the future experts. Principles of nonmaleficence, duty, unconditional
value of human life, collectivity – all these moral duties of a doctor have for a long
time been an essence of the maintenance of medical deontology and ethics and
were considered as constant traits. In the second half of the 20 th century the
situation started to change with the occurrence on a new and wide area of
interdisciplinary researches – bioethics. The foundation of bioethics as a new
doctrine in the system of public health services has demanded an ethical-
philosophical reflection of moral principles and rules of law, world outlook and
methodological settings, raising the question of morals in natural sciences and,
first of all, in medicine. Undoubtedly, the major reasons of its occurrence are the
rapid development of fundamental medical and biologic sciences, and the
technologies associated with them, consequences of introduction and application
of which raise serious reservations (methods of artificial fertilization, surrogate
motherhood, transplantation of human organs and tissues, prenatal diagnostics,
genetic consultation). Significant changes and evolution took place in the «doctor-
patient» system, from unconditional acceptance of paternalism up to a developing
of contractual models in the modern practice of public health. We shall also note
the fundamentally new approach to the patients’ rights in acceptance of the
medical help. Namely, the right to autonomy of a person, the right to the
information on the diagnosis and the forecast of disease, the right to a choice of
treatment and refusal of it. All these standards have found the reflection in modern
international documents of medical ethics.
The reassessment of the main ethical and legal priorities of applied medicine
and biomedicine in the context of various paradigms of humanism allows to
understand that any activity of a doctor or a pharmaceutical professional should
with necessity lean on principles and norms of morals. Bioethics as the intellectual
space for a dialogue of essentially different social and ethical positions, promotes
understanding of specifics of the moral aspects in the profession of a doctor and
realization of principles of general morals in the field of medicine. In view of
applied character of professional medical ethics the majority of the developed
problems of bioethics have enormous value for the progress of the clinical
medicine, appearance of such forms of organizations and public health services
which are one of the major parameters of development of a modern civilization as
a whole.

5
 Dean of the department of foreign students, doctor of medicine,
рrofessor Y.D. Lyashev.

6
 ETHICS. BIOETHICS.
I. The Definition of Ethics.
II. The Divisions of Ethics.
III. Bioethics.
IV. The Foundations of Bioethics.
V. Ethic Codes.

Literature
Athanassoulis, Nafsika, ed. Philosophical Reflections on Medical Ethics.
Basingstoke [England]/New York: Palgrave/Macmillan, 2005.
Engelhardt HT Jr. The Foundations of Bioethics. 2nd ed. New York:
Oxford University Press; 1996.
Gert, Bernard; Culver, Charles M.; and Clouser, K. Danner. Bioethics: a
Systematic Approach. Oxford/New York: Oxford University Press, 2006.
Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics. 4th ed. New York:
McGraw-Hill; 1998.
Potter, Van Rensselaer. Global Bioethics: Building on the Leopold
Legacy. East Lansing. Michigan State University Press. 1988.

Reports, synopses, course and term paper

Ethical Issues in Modern Medicine.
Law, Ethics and Bioethics.
The History of Medical Ethics.
Perspectives of Bioethics.

Ethics is a general term for what is often described as the «science of

morality». Morality is a complex of principles based on cultural, religious,
and philosophical concepts and beliefs. Like most contemporary texts,
ours will treat ethics and morality as roughly synonymous. This is in
keeping with the etymology of the two words. Moral derives from the

7
Latin word moralis. Moralis was a term that ancient Roman philosopher
Cicero made up to translate the ancient Greek ethikos into Latin. Both
mean, roughly, «pertaining to character» but today their contemporary
derivatives deal with much more than character. The Western tradition of
ethics is sometimes called moral philosophy. The formal study of ethics in
a serious and analytical sense began with the early Greeks, and later
Romans. Most prominent Greek ethicists were the Sophists, Socrates,
Plato and Aristotle. Philosophers today usually divide ethical theories into
three general subject areas: metaethics, normative ethics, and applied
ethics.
Metaethics investigates where our ethical principles come from, and
what they mean. The term «meta» means after or beyond, and,
consequently, the notion of metaethics involves a removed of the entire
project of ethics branch. Metaethics focuses on the issues of universal
truths, the will of God, the role of reason in ethical judgments, and the
meaning of ethical terms themselves. We may define metaethics as the
study of the origin and meaning of ethical concepts.
Examination of the adequacy of moral or ethical values, standards or
judgments is normative ethics. Normative ethics may involve articulating
the good habits that we should acquire, the duties that we should follow, or
the consequences of our behavior on others. Normative ethics involves
arriving at moral standards that regulate right and wrong conduct. The
Golden Rule is a classic example of a normative principle: We should do
to others what we would want others to do to us. Since I would like people
to feed me if I am starving, then I should help feed starving people. Using
this same reasoning, we can theoretically determine whether any possible
action is right or wrong. So, based on the Golden Rule, it would also be
wrong for me to lie to, harass, victimize, assault, or kill others. The Golden
Rule is an example of a normative theory that establishes a single principle
against which we judge all actions. Other normative theories focus on a set

8
of foundational principles, or a set of good character traits. The key
assumption in normative ethics is that there is only one ultimate criterion
of moral conduct, whether it is a single rule or a set of principles. Three
strategies will be noted here: 1) virtue theories, 2) duty theories, and 3)
consequential theories.
Applied ethics is the branch of ethics which consists of the analysis
of specific, controversial moral issues. Aristotle, for example, believed that
there was no point in studying ethics unless it would have some beneficial
effect on the way one lived one’s life. In recent years applied ethical issues
have been subdivided into convenient groups such as medical ethics,
business ethics, environmental ethics, and sexual ethics. Generally
speaking, two features are necessary for an issue to be considered an
«applied ethical issue». First, the issue needs to be controversial in the
sense that there are significant groups of people both for and against the
issue at hand. The second requirement for an issue to be an applied ethical
issue is that it must be a distinctly moral issue.
The term bioethics, as it was first used by biologist Van Rensselaer
Potter, referred to a new field devoted to human survival and an improved
quality of life, not necessarily or particularly medical in character. The
term soon was used differently, particularly to distinguish it from the much
older field of medical ethics. The latter had traditionally been marked by a
heavy, almost exclusive emphasis on the moral obligations of physicians
and on the doctor-patient relationship. Yet that emphasis, while still
important, was not capacious enough to embrace the huge range of
emerging issues and perspectives. Bioethics came to refer to the broad
terrain of the moral problems of the life sciences, ordinarily taken to
encompass medicine, biology, and some important aspects of the
environmental, population, and social sciences. The traditional domain of
medical ethics would be included within this array, accompanied now by
many other topics and problems. Such as issues over the definition of

9
death and the withdrawal of life-sustaining medical treatment, prenatal
diagnosis and abortion, the storage of frozen human embryos, the use of
humans, animals, or fetal tissue for scientific research, the screening of
persons for the AIDS virus or other infections, the disposition of toxic
wastes, the expansion of genetic engineering and others. Bioethics
represents a radical transformation of the older, more traditional domain of
medical ethics; yet it is also true that, since the dawn of history, healers
have been forced to wrestle with the human fear of illness and death, and
with the limits imposed by human finitude. So, bioethics refers to the
moral issues and problems that have arisen as a result of modern medicine
and research. It has reached into law and public policy, into literary,
cultural, and historical studies, into the popular media, into the disciplines
of philosophy, religion, and literature, and into the scientific fields of
medicine, biology, ecology and environment, demography, and the social
sciences. Finally, the growth of interdisciplinary and multidisciplinary
work in academic institutions has facilitated dealing concurrently with
biological research and with moral and social issues of human behavior.
The first bioethics study institute, the Hasting Center (UK), was
established in June 1969. In 1971 Georgetown University in Washington
established The Joseph and Rose Kennedy Institute of Ethics, which
created a Center for Bioethics and sponsored the publication of the first
Encyclopedia of Bioethics. By the 1990s there were over a hundred
bioethics organizations worldwide. Centers for research in bioethics have
been established in Austria, Britain, Canada and other countries. Many
medical schools have added the discussion of ethical issues in medicine to
their curricula. Governments have sought to deal with the most
controversial issues by appointing special committees to provide ethical
advice.
One of most important bioethic problems is the problem of what
moral theories or perspectives are most helpful in responding to moral

10
issues and dilemmas. The traditions of medicine, emphasizing the
complexity and individuality of particular moral decisions at the bedside,
have been prone to emphasize those virtues thought to be most important
in physicians. They include dedication to the welfare of the patient and
empathy for those in pain. Some philosophical traditions, by contrast, have
placed the emphasis on principlism — the value of particular moral
principles that help in the actual making of decisions. These include the
principle of respect for persons, and most notably respect for the autonomy
of patients; the principle of beneficence, which emphasizes the pursuit of
the good and the welfare of the patient; the principle of nonmaleficence,
which looks to the avoidance of harm to the patient; and the principle of
justice, which stresses treating persons fairly and equitably. The advantage
of principles of this kind is that, in varying ways and to different degrees;
they can be used to protect patients against being harmed by medical
practitioners and to identify the good of patients that decent medical and
healthcare should serve. Yet how are such principles to be grounded, and
how are we to determine which of the principles is more or less important
when they conflict? Moral principles have typically been grounded on
broad theories of ethics-utilitarianism, for example, which justifies act as
moral on the basis of the consequences of those acts (sometimes called
consequentialism).
Utilitarian approaches ask which consequences of a choice or an
action or a policy would promote the best possible outcome. That outcome
might be understood as maximizing the widest range of individual
preferences, or promoting the greatest predominance of good over evil, or
the greatest good of the greatest number. Such an approach to healthcare
rationing, for instance, would look for the collective social benefit rather
than advantages to individuals.
Deontology focuses on determining which choices most respect the
worth and value of the individual, and particularly the fundamental rights

11
of individuals. From a deontological perspective, good consequences may
on occasion have to be set aside to respect inalienable human rights. It
would be wrong, for instance, to subject a human being to dangerous
medical research without the person's consent even if the consequences of
doing so might be to save the lives of many others. Our transcendent
obligation is toward the potential research subject.
Not all debates about moral theory come down to struggle between
utilitarianism and deontology, though that struggle has been central too
much of the moral philosophy that influenced bioethics in its first
decades. Other moral theories, such as that of Aristotle, stress neither
principles nor consequences but see a combination of virtuous character
and seasoned practical reason as the most likely source of good moral
judgment. For that matter, a morality centering on principles raises the
problems of the kind of theory necessary to ground those principles, and of
how a determination of priorities is to be made when the principles
conflict. A respect for patient autonomy, stressing the right of competent
patients to make their own choices, can conflict with the principle of
beneficence if the choice to be made by the patient may actually be
harmful. And autonomy can also conflict with the principle of
nonmaleficence if the patient's choice would seem to require that the
physician be the person who directly brings harm to the patient.
Another classical struggle turns on the dilemma that arises when
respect for individual freedom of choice poses a threat to justice,
particularly when an equitable distribution of resources requires limiting
individual choice. Autonomy and justice are brought into direct conflict.
Recent debates on healthcare rationing, or setting priorities, have made
that tension prominent.
Applied ethics has emphasized drawing those principles from still
broader ethical theory, whose role is to ground the principles. Moral
analysis, then, works from the top down, from theory to principles to case

12
application. An alternative way to understand the relationship between
principles and their application, far more dialectical in its approach, is the
method of wide reflective equilibrium. It espouses a constant movement
back and forth between principles and human experience, letting each
correct and tutor the other.
Still another approach is that of casuistry, drawn from methods
commonly used in the Middle Ages. In contrast with principlism, it works
from the bottom up, focusing on the practical solving of moral problems by
a careful analysis of individual cases. A casuistical strategy does not reject
the use of principles but sees them as emerging over time, much like the
common law that has emerged in the Anglo-American legal tradition.
Moral principles derive from actual practices, refined by reflection and
experience. Those principles are always open to further revision and
reinterpretation in light of new cases. At the same time, a casuistical
analysis makes prominent use of analogies, employing older cases to help
solve newer ones. If, for instance, general agreement has been reached that
it is morally acceptable to turn off the respirator of a dying patient, does
this provide a good precedent for withdrawing artificially provided
hydration and nutrition? Is the latter form of care morally equivalent to
the former, so that the precedent of the former can serve to legitimate the
latter? Those are the kinds of questions that a casuistical analysis would
ask. At the same time, a casuistical analysis runs the risk of being too
bound to past cases and precedents. It can seem to lack the capacity to
signal the need for a change of moral direction.
Still another principle-oriented approach proposes a new social
contract between medicine and society. Such a contract would be
threefold. It comprises basic ethical principles for society as a whole, a
contract between society and the medical profession about the latter's
social role, and a contract between professionals and laypersons that
spells out the rights and prerogatives of each. This strategy is designed

13
both to place the ethics of medicine squarely within the ethical values of
the larger society and to make sure that laypeople have sufficient choice
and power to determine the kind of care they, and not paternalistic
physicians, choose. Still another approach, more skeptical about finding
any strong consensus on ethical foundations, stresses an ethic of secular
pluralism and social peace, devising a minimal ethic for the community as
a whole but allowing great play to the values and choices of different
religious and value subcommunities.
Ethical codes are integral part of history of medical ethics.
Professional codes have evolved throughout history as practitioners
grappled with various ethical and bioethical issues. The Oath of
Hippocrates, which was written in the fifth century, is one of the first and
best codes of medical ethics of European medicine. A famous, time-
honoured rule ascribed to Hippocrates is Primum non nocere («first, do
no harm»); another one is Ars longa, vita brevis («art is long, and life
short»). The so-called Hippocratic Oath was an unquestionable example
for medical etiquette for centuries, and it endures in modified form to this
day.
The Geneva Convention Code of Medical Ethics, established by the
World Medical Association in 1949, is similar to the Hippocratic Oath.
This code refers to colleagues as brothers and states that religion, race and
other factors are not consideration for care of the total person. This code
reflects the fact that medicine was becoming available to all during this
era.
The Nuremberg Code was established between 1946 and 1949 as a
result of trials of war criminals after World War II. This code suggests
guidelines for human experimentation and is directed to the world. The
writers hoped that the code would ensure the safety of humans in the years
to come.
The Declaration of Helsinki, written between 1964 and 1975, is an

14
update on human experimentation. Much more detailed than the
Nuremberg Code, it includes guidelines for both therapeutic and scientific
clinical research. Unlike the Nuremberg Code, the Declaration of Helsinki
is directed to the world of medicine rather than the world at large.
In 1997 Council of Europe adopted Convention for the Protection of
Human Rights and Dignity of the Human Being with regard to the
Application of Biology and Medicine: Convention on Human Rights and
Biomedicine.

THE MAIN PRINCIPLES OF BIOETHICS

I. The Principle of Nonmaleficence.
II. The Principle of Beneficence.
III. The Principle of Respect for Autonomy.
IV. The Principle of Justice.

Literature
Beauchamp TL, Childress JF. Principles of Biomedical Ethics. New York:
Oxford University Press, 4th edition, 1994.
Brody H. The Healers' Power. New Haven and London: Yale University
Press, 1992.
Kleinman A. The Illness Narratives: Suffering, Healing, and the Human
Condition. New York: Basic Books; 1988.
Purtilo, Ruth B. Ethical Dimensions in the Health Professions.
Philadelphia: Elsevier Saunders, 2005.
Rescher, Nicholas. Fairness: Theory & Practice of Distributive Justice.
New Brunswick, NJ: Transaction, 2002.
Rodwin MA. Medicine, Money, and Morals. New York: Oxford
University Press, 1993.
Viafora, Corrado, ed. Clinical Bioethics: a Search for the Foundations.
Dordrecht/ Boston: Springer, 2005.

15
 Reports, synopses, course and term paper
Modern Biomedical Technology and Situation of Moral Choice in
Medicine.
Deontology Model in Medicine.
Problem of Justice in Modern Medicine.
Treatment Refusal and Personal Autonomy.

The proper goal of medicine is to prevent, alleviate, or eliminate

harm to patients that result from disease or injury. Moreover, some
medical interventions themselves have a serious potential to cause
additional (iatrogenic) harm for instance, pharmacological side effects or
even death from surgery. Bioethics is concerned with harm-related
judgments, obligations, prohibitions, and problems. According to the
Oxford English Dictionary, harm is «evil (physical or otherwise) as done
to or suffered by some person or thing; hurt, injury, damage, mischief». As
far as harm is relevant to moral deliberation, however, this broad concept
must be restricted.
First, harm should be understood as person (or animal) regarding,
that is, as consisting of events or states of affairs that are negative for
someone as expressed in Joel Femberg's definition of harms as «setbacks
to interest».
Secondly, ethics in general ethics and bioethics in particular have to
restrict their focus on those instances of harm that: are in some way or
other linked to human action, would not make sense to morally deliberate
about ineluctable evils, deplorable though they may be.
Rather, harm is ethically relevant only if it occurs or persists in
consequence to human agency, be it by action or omission, from intention
or negligence, but not from unavoidable ignorance. Thus, what counts as
harm with relevance to bioethics is context-relative: harm is contingent
upon professional knowledge and medico-technical progress.

16
 Thirdly, bioethics, reflecting both ordinary moral and non-moral
language usage, commonly differentiates between harm on the one hand
and mere loss or lack of benefit on the other. Harm is not simply
conceptually complementary to benefit but it also represents a significant
disservice to its victim. Along the scale of interest satisfaction, there are
numerous positions of submaximal satisfaction (disbenefits) that it seems
inappropriate to call harms. There is thus an asymmetry between harm and
benefit in the sense that harm pertains exclusively to the basics of well-
being. A good argument elucidating this asymmetry emphasizes that harm
has or leads to distinct phenomenal qualities of bodily or psychological
painfulness and suffering, which is by no means true for all instances of
lacking benefit.
Not to inflict, to prevent, or to remove harm usually takes moral
precedence over providing those benefits the lack of which are not counted
as harm. Such asymmetry between harm and benefit has been traditionally
acknowledged (e.g., by John Stuart Mill). A more systematic focus on
harm is a rather recent development of applied ethics, with its eye to more
concrete moral rules (a notable exception being Jeremy Bentham's 1789
taxonomy of «pains» by sources, kinds, and circumstances). The
improvement of people's well-being being a more or less central goal of
any moral code, concrete efforts must first focus on the most important
obstacles to well-being, that is, on existing or potential harm.
Primum non nocere (First, do no harm) is thought to be at the nexus
of traditional health care ethics and often is attributed to the author of the
Hippocratic Oath. The principle of nonmaleficence requires of physician
that he/she not intentionally create a needless harm or injury to the patient,
either through acts of commission or omission. In common language, we
consider it negligence if one imposes a careless or unreasonable risk of
harm upon another. Providing a proper standard of care that avoids or
minimizes the risk of harm is supported not only by our commonly held

17
moral convictions, but by the laws of society as well. In a professional
model of care one may be morally and legally blameworthy if one fails to
meet the standards of due care. The legal criteria for determining
negligence are as follows: the professional must have a duty to the affected
party; the professional must breach that duty; the affected party must
experience a harm; the harm must be caused by the breach of duty.
This principle affirms the need for medical competence. It is clear
that medical mistakes occur. However, this principle articulates a
fundamental commitment on the part of health care professionals to protect
their patients from harm.
This principle expresses the concept that professionals have a duty to
act for the benefit of others. Under this principle, the physician’s 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
health 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. We apply the same ethical considerations whether the
professional is engaged in fee-for-service managed care or some other
practice arrangement. Physicians may choose to enter into contracts
governing the provision of care to a group of patients; however, contract
obligations do not excuse physicians from their ethical duty to put the
patient's welfare first.
The ordinary meaning of this principle is the duty of health care
providers to be of a benefit to the patient, as well as to take positive steps
to prevent and to remove harm from the patient. These duties are viewed
as self-evident and are widely accepted as the proper goals of medicine.
These goals are applied both to individual patients, and to the good of
society as a whole. For example, the good health of a particular patient is
an appropriate goal of medicine, and the prevention of disease through
research and the employment of vaccines is the same goal expanded to the

18
population at large. It is sometimes held that nonmaleficence is a constant
duty, that is, one ought never to harm another individual. Whereas,
beneficence is a limited duty. A physician has a duty to seek the benefit of
any or all of her patients, however, the physician may also choose whom
to admit into his or her practice, and does not have a strict duty to benefit
patients not acknowledged in the panel. This duty becomes complex if two
patients appeal for treatment at the same moment. Some criteria of urgency
of need might be used, or some principle of first come first served, to
decide who should be helped at the moment.
Twenty-five years ago, most major medical decisions were left
exclusively in the hands of physicians. They were usually made with
beneficent intent but without open discussion, much less the full
participation of the patient. This paternalistic approach had some benefits.
Physicians now see obvious problems with excessive paternalism: It can
be difficult to determine what the patient's best interests are; inappropriate
biases caused by sex, race, and socioeconomic status can affect decision
making. Patients can be deprived of the opportunity to make decisions that
reflect the reality of their conditions. The principle of respect for autonomy
is based on a person's right to self-determination. In health care decisions,
physician’s respect for the autonomy of the patient would, in common
parlance, mean that the patient has the capacity to act intentionally, with
understanding, and without controlling influences that would mitigate
against a free and voluntary act. The physician should objectively answer
questions but should avoid influencing the patient to take one path or
another, even if the physician has strong opinions or if the patient asks for
advice. After the patient makes the decision, the physician's duty is to
implement the medical aspects of that decision. The physician-patient
dialogue that characterizes the enhanced autonomy model includes active
listening, honest sharing of perspectives, suspension of judgment, and
genuine concern about the patient's best interests. This principle is the

19
basis for the practice of «informed consent» in the physician/patient
transaction regarding health care.
The central philosophical point of autonomy is respect for the patient
as a person. Respecting a person means taking the time to listen to that
person's unique story and ensuring that medical decisions are integrated
into the current chapter of the patient's biography. If a patient's decision
does not make sense in the context of his or her unique story, physicians
must explore and come to understand discrepancies by asking detailed
questions and openly sharing discomfort. Although the final decisions
belong to patients, the decisions that result from the intense exchange of
medical information, values, and experiences between physician and
patient are generally more informed and autonomous than are those made
simply on the basis of patient requests.
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 physician's primary obligations include dealing with people
justly and delivering health care without prejudice. In its broadest sense,
this principle expresses the concept that the medical profession should
actively seek allies throughout society on specific activities that will help
to improve the access to care for all. Justice in health care is usually
defined as a form of fairness, or as Aristotle once said, «giving to each that
which is his due». This implies the fair distribution of goods in society and
requires that we look at the role of entitlement. The question of distributive
justice also seems to hinge on the fact that some goods and services are in
short supply, there is not enough to go around, thus some fair means of
allocating scarce resources must be determined. It is generally held that
persons who are equals should qualify for equal treatment. In fact, our
society uses a variety of factors as a criteria for distributive justice,
including the following:
 to each person an equal share

20
  to each person according to need
 to each person according to effort
 to each person according to contribution
 to each person according to merit
 to each person according to free-market exchanges
John Rawls and others claim that many of the inequalities we
experience are the result of a «natural lottery» or a «social lottery». One of
the most controversial issues in modern health care is the question
pertaining to «who has the right to health care? ». Or, stated another way,
perhaps as a society we want to be beneficent and fair and provide some
decent minimum level of health care for all citizens, regardless of ability to
pay.

THE MAJOR RULES OF BIOMEDICAL PRACTICE

I. Informed Consent.
II. Confidentiality.
III. Truth-telling Information.

Literature
Applebaum PS, Lidz CW, Meisel A. Informed Consent: Legal Theory and
Clinical Practice. New York: Oxford University Press, 1987.
Ashcroft, Richard; Lucassen, Anneke; Parker, Michael; Verkerk, Marian;
and Widdershoven, Guy, eds. Case Analysis in Clinical Ethics.
Cambridge/New York: Cambridge University Press, 2005.
Buchanan, Allen E. and Brock, Dan W. Deciding for Others: The Ethics of
Surrogate Decision Making. New York: Cambridge University Press,
1989.
Hebert, PC.  Doing Right:  A Practical Guide to Ethics for Medical
Trainees and Physicians.  Toronto:  Oxford University Press, 1996.
Kennedy, Ian and Grubb, Andrew. Medical Law. Oxford/New York:

21
Oxford University Press, 2005.
Rothman, David J. Strangers at the Bedside: A History of How Law and
Bioethics Transformed Medical Decision Making. New York: Basic
Books, 1991.

22
 Reports, synopses, course and term paper
The History of Confidentiality in Medicine.
Violation of Confidentiality and the Responsibility of Physicians.
The Problem of the Lie in Medicine.
Medical Research Involving Human Subjects and Informed Consent.

The term «informed consent» used to describe the obligation of

physicians or researchers to allow patients or subjects to be active
participants in decisions regarding their care or participation in research.
Informed consent is rooted in the concept of autonomous choice or the
right of self-determination. Beauchamp and Childress describe three main
aspects of informed consent and explain the elements needed for each
aspect.

Threshold Elements (preconditions)

competence (to understand and decide)
voluntariness (in deciding)

Information Elements
disclosure (of material information)
recommendation (of a plan)
understanding (of disclosure and comprehension)
Consent elements
decision (in favor of a plan)
authorization (of the chosen plan; with an understanding that it is an
authorization).

The most important goal of informed consent is that the patient has
an opportunity to be an informed participant in his health care decisions. It
is generally accepted that complete informed consent includes a discussion

23
of the following elements:
 the nature of the decision/procedure
 reasonable alternatives to the proposed intervention
 the relevant risks, benefits, and uncertainties related to each
alternative
 assessment of patient’s understanding
 the acceptance of the intervention by the patient
So that the patient's consent is valid, he must be considered
competent to make the decision at hand and his consent must be voluntary.
All adult patients are considered competent to make decisions about
medical care unless a court declares them incompetent. In clinical practice,
however, physicians and family members usually make decisions without
formal competency hearing in the courts for patients who lack decision-
making capacity. This clinical approach can be ethically justified if the
physician has carefully determined that the patient is incapable of
understanding the nature of the proposed treatment, the alternatives to it,
and the risks, benefits, and its consequences. Patients often feel powerless
and vulnerable. To encourage voluntariness, the physician can make clear
to the patient that he is participating in a decision, not merely signing a
form. With this understanding, the informed consent process should be
seen as an invitation to him to participate in his health care decisions. The
physicians are also generally obligated to provide a recommendation and
share their reasoning process with the patient. Comprehension on the part
of the patient is equally as important as the information provided.
Consequently, the discussion should be carried on in layperson's terms and
the patient's understanding should be assessed along the way.
Consent may be either expressed or implied. The expressed consent
most often occurs in the hospital setting, where written or oral consent is
given for a particular procedure. In many medical encounters, when the
patient is presented to a physician for evaluation and care, consent can be

24
presumed. The patient’s condition and treatment options are explained to
the patient, and treatment is rendered or refused. In medical emergencies,
consent to treatment that is necessary to maintain life or restore health is
usually implied unless it is known that the patient would refuse the
intervention. Most health care institutions have policies that state which
health interventions require a signed consent form. For example, surgery,
anesthesia, and other invasive procedures are usually in this category.
These signed forms are really the culmination of a dialogue required to
foster the patient's informed participation in the clinical decision.
Sometimes it is so difficult to understand when a physician has said
enough about the certain decision. Most of the literature and law in this
area offer one of three approaches: reasonable physician standard,
reasonable patient standard, subjective standard.
Reasonable physician standard: what would a typical physician say
about this intervention?
Reasonable patient standard: what would an average patient need to
know in order to be an informed participant in the decision making?
Subjective standard: what would this patient need to know and
understand in order to make an informed decision?
The best approach to the question of how much information is
enough is one that meets both your professional obligation to provide the
best care and respects the patient as a person with the right to a voice in
health care decisions.
In most cases, it is clear whether or not patients are competent to
make their own decisions. Occasionally, it is not so clear. Patients are
under unusual amount of stress during illness and can experience anxiety,
fear, and depression. The stress associated with illness should not
necessarily preclude one from participating in one's own care. However,
precautions should be taken to ensure the patient does have the capacity to
make good decisions. There are several different standards of decision

25
making capacity. Generally a physician should assess the patient's ability
to:
 understand his or her situation
 understand the risks associated with the decision
 communicate a decision based on that understanding.
When a patient lacks decision-making capacity (that is, the ability to
receive and express information and to make a choice consonant with that
information and one's values), an appropriate surrogate should make
decisions with the physician. Ideally, surrogate decision makers should
know the patient's preferences and act in the best interests of the patient. If
the patient has designated a proxy, as through a durable power of attorney
for health care, that choice should be respected. When patients have not
selected surrogates, standard clinical practice is that family members serve
as surrogates. Some states designate the order in which family members
will serve as surrogates. Physicians should be aware of legal requirements
in their state for surrogate appointment and decision making. In some
cases, all parties may agree that a close friend is a more appropriate
surrogate than a relative.
Confidentiality is a fundamental tenet of medical care. It is a matter
of respecting the privacy of patients, encouraging them to seek medical
care and discuss their problems candidly, and preventing discrimination on
the basis of their medical conditions. The physician must not release
information without the patient's consent.
However, confidentiality, like other ethical duties, is not absolute. It
may have to be overridden to protect individual persons or the public or to
disclose information when the law requires it. A patient may, for instance,
disclose to his doctor that he believes his sister is an evil witch. His
delusion is also linked to a plan to kill her. The doctor must weigh up his
duty to his patient to maintain confidentiality against a duty to protect the
unknown sister. This dilemma involves a conflict between the principles of

26
autonomy and nonmaleficence. Before breaching confidentiality, the
physician should make every effort to discuss the issues with the patient. If
breaching confidentiality is necessary, it should be done in a way that
minimizes harm to the patient and that requires applicable federal law.
Confidentiality is increasingly difficult to maintain in the era of
computerized record keeping and electronic data processing, faxing patient
information, third-party payment for medical services, and sharing patient
care among numerous medical professionals and institutions. Physicians
should be aware of the increased risk for intervention into patients' privacy
and should help ensure confidentiality. Within their own institutions,
physicians should advocate policies and procedures to secure the
confidentiality of patient records.
Discussion of the problems of an identified patient by professional
staff in public places (for example, in elevators or in cafeterias) violates
confidentiality and is unethical. Outside of an educational setting,
discussions of a potentially identifiable patient in front of persons who are
not involved in that patient's care are unwise and impair the public's
confidence in the medical profession. Physicians of patients who are well
known to the public should remember that they are not free to discuss or
disclose information about patient's health without the explicit consent of
the patient.
In the care of the adolescent patient, family support is important.
However, this support must be balanced with confidentiality and respect
for the adolescent's autonomy in health care decisions and in relationships
with health care providers. Physicians should be knowledgeable about
state laws governing the right of adolescent patients to confidentiality and
the adolescent's legal right to consent to treatment.
While there may be cases where the physician feels compelled to
share information regarding the patient's health and prognosis with, for
instance, the patient's inquiring spouse, without explicit permission from

27
the patient it is generally unjustifiable to do so. Except cases where the
spouse is at specific risk of harm directly related to the diagnosis, it
remains the patient's, rather than the physician's, obligation to inform the
spouse. The physician should always act in the best interests of the patient.
Ethical issues arise with regard to publication. Most journals now
require explicit consent from patients if their case history is to be used in
publication.
The historical medical codes addressed issues like not doing harm,
not taking life, not revealing secrets, but said little or nothing about telling
the truth and avoiding lies. The value of not doing harm was so strong that
lying in order to avoid harm was considered acceptable, a twisted form of
medical virtue. Since communicating the truth about disease is difficult,
many physicians simply discounted or ignored the moral problem of
truthfulness in the doctor-patient relationship. The importance of not doing
harm in effect relegated truth telling to the category of «tell the truth as
long as it helps rather than harms the patient».
Because of the historical centrality of nonmaleficence, and as telling
the truth about fatal or even serious diagnoses was assumed to cause harm
to the patient, physicians traditionally did not tell the truth to patients.
Many moral philosophers referred to physician’s discourse with patients as
an exception to the obligation to tell the truth. The doctor's principal moral
obligation was to help and not to harm the patient and consequently,
whatever the doctor said to the patient was judged by its effect on these
core duties.
Today, things have changed. Beneficence and nonmalefiсence
remain basic medical ethical principles, but truth is also a medical ethical
standard. The importance of truth telling in the clinical context derives
from taking more seriously the patient's perspective in medical ethics. The
historical justifications of lying to patients articulate the perspective of the
liar, not that of a person being lied to. In most cases people are hurt when

28
they are deliberately deceived. This is especially true of patients. This may
not have been so historically, but it is definitely true today. The
requirement of honesty is clearly linked today with the patient's new legal
right to give informed and free consent or refusal of treatment. Patient’s
power in the doctor/patient relationship is the distinguishing element of
modern medical ethics. In requiring adequate information for decision
making, modern medical ethics broke with the paternalistic tradition.
Traditionally the doctor did not tell the truth lest the patient be harmed.
Now, not to harm the patient requires in most instances that patients be
truthfully informed and then invited to participate in clinical decision
making.
Not telling the truth in the doctor-patient relationship requires special
attention because patients today, more than ever, experience serious harm
if they are lied to. They need it because they are ill, vulnerable, and
burdened with pressing questions which require truthful answers. Honesty
also matters to the doctor and other medical professionals. The loss of
reputation for honesty in medical practice means the end of medicine as a
profession.
Inattention to truth or violations of honesty by medical personnel is
serious business, which concerns nurses, researchers and other health
professionals. The truth issue is worth thinking about by all health-care
professionals. In some cases the harm from not telling the truth may be
less. Some degree of dishonesty may even be excusable sometimes in
order to avoid more serious harm to a patient. If there are reasons for not
telling the truth, what are they? When could incomplete disclosure be
justified and under what circumstances? What exceptions, if any, exist to
the rule against lying? What kinds of arguments support the answers to
these questions?
There are the limits to which a doctor or a nurse can disclose the
truth. Doctors and nurses have duties to others besides their patients; their

29
professions, public health law, science, to mention just a few. They also
have obligations created by institutional policies, contractual
arrangements, and their own family commitments. Many moral obligations
a nurse or physician may have to persons and groups other than to the
patient complicates the question of just how much a professional should
disclose to his or her patients. Doctors and nurses in some cultures believe
that it is not wrong to lie about a bad diagnosis or prognosis. Certainly this
is a difficult truth to tell but on balance, there are many benefits in telling
the truth and many reasons not to tell a lie. Tolstoy gave us a powerful
message about the harms which follow lying to the dying patients in The
Death of Ivan Illich, and his insights came out of a culture which assumed
that lying was the right thing to do in such circumstances. Lying in a
clinical context is wrong for many reasons but less than full disclosure
may be morally justifiable. If a patient is depressed and irrational and
suicidal, then caution is required lest full disclosure may contribute to
grave harm. If a patient is overly pessimistic, disclosure of negative
possibilities may actually contribute to actualizing these very possibilities.
Doctors and nurses, however, can do as much harm by cold and crude
truth-telling as they can by cold and cruel withholding of the truth. To tell
the truth in the clinical context requires compassion, intelligence,
sensitivity, and a commitment to staying with the patient after the truth has
been revealed. Besides to tell the truth is not to deny hope. Hope and
truth and even friendship and love are all parts of ethics of caring to the
end.

PHYSICIAN-PATIENT RELATIONSHIP
I. Physician as a Professional.
II. Trust between a Patient and Providers.
III. Mistakes.

30
 Literature
Brody H. The Healer's Power. New Haven: Yale University Press, 1992.
Contemporary Issues in Bioethics. Edited by Tom L. Beauchamp and
LeRoy Walters. 4th ed. Belmont, CA: Wadsworth Publishing Co., 1994.
Glannon, Walter Biomedical Ethics. New York: Oxford University Press,
2005. Pozgar, George D. Legal and Ethical Issues for Health Professionals.
Sudbury, MA: Jones and Bartlett, 2005.
Rescher, Nicholas. Fairness: Theory & Practice of Distributive Justice.
New Brunswick, NJ: Transaction, 2002.

Reports, synopses, course and term paper

The Recognized Obligations and Values of a Professional Physician.
The Professional Culture of a Physician.
Mistakes in Medicine: Personal and Moral Responses.
Error as a System Problem.

Medicine is a traditional profession, such as law, education and

clergy. The words «profession» and «professional» come from the Latin
word «profession», which means a public declaration with the force of a
promise. Professions are groups which declare in a public way that their
members will act in certain ways and that the group and the society may
discipline those who fail to do so. The profession presents itself to society
as a social benefit and society accepts the profession, expecting it to serve
some important social goal.
The marks of a profession are:
competence in a specialized body of knowledge and skill;
an acknowledgment of specific duties and responsibilities toward the
individuals it serves and toward society;
the right to train, admit, discipline and dismiss its members for
failure to sustain competence or observe the duties and responsibilities.

31
 The historical model for the physician-patient relationship involved
patient`s dependence on the physician's professional authority. Believing
that the patient would benefit from the physician's actions, patient's
preferences were generally overridden or ignored. For centuries, the
concept of physician beneficence allowed this paternalistic model to
thrive. During the second half of the twentieth century, the physician-
patient relationship has evolved towards shared decision making. This
model respects the patient as an autonomous agent with a right to hold
views, to make choices, and to take actions based on personal values and
beliefs. Patients have been increasingly entitled to weigh the benefits and
risks of alternative treatments, including the alternative of no treatment,
and to select the alternative that best promotes their own values. The
patient–physician relationship entails special obligations for the physician
to serve the patient's interest because of the specialized knowledge that
physicians hold and the imbalance of power between physicians and
patients.
The physician's primary commitment must always be to the patient's
welfare and best interests, whether the physician is preventing or treating
illness or helping patients to cope with illness, disability, and death. The
physician must support the dignity of all persons and respect their
uniqueness. The interests of the patient should always be promoted
regardless of financial arrangements; the health care setting; and patient`s
characteristics, such as decision-making capacity or social status.
At the beginning of a patient–physician relationship, the physician
must understand the patient's complaints, underlying feelings, goals, and
expectations. After a patient and a physician agree on the problem and the
goal of therapy, the physician presents one or more courses of action. If
both parties agree, the patient may authorize the physician to initiate a
course of action; the physician can then accept that responsibility. The
relationship has mutual obligations: the physician must be professionally

32
competent, act responsibly, and treat the patient with compassion and
respect, and the patient should understand and consent to the treatment that
is rendered and should participate responsibly in the care. Although the
physician should be fairly compensated for services rendered, a sense of
duty to the patient should take precedence over concern about
compensation when a patient's well-being is at stake.
The patient demands from the physician both a high level of
competence (both judgment and skill) and a concern for the patient's well-
being. For healthcare professionals to behave in a responsible or
trustworthy way requires both technical competence and moral concern-
specifically, a concern to achieve a good outcome in the matter covered,
which is sometimes called «fiduciary responsibility», the responsibility of
a person who has been entrusted in some way. The moral and technical
components of professional responsibility have led sociologist Bernard
Barber to speak of these as two «senses» of trust. However, if the patient
trusts the surgeon, it is not in two senses; the patient trusts the surgeon
simply to provide a good, or perhaps the best, outcome for the patient. To
fulfill that trust, the surgeon has to be both morally concerned for the
patient's well-being (or at least health outcome) and technically competent.
Since the exercise of professional responsibility characteristically
draws on a body of specialized knowledge that is brought to bear on the
promotion or preservation of another's welfare, to trust someone to fulfill a
professional responsibility means to trust that a person to perform in a way
that someone outside that profession cannot entirely specify, predict, or
often even recognize. In drawing attention to this point, Trudy Govier
says that trust is «open-ended». The point is not captured in the frequent
suggestion that trust is necessary because the trusting party cannot control
or monitor the trusted party's performance. It would do the patient little
good to have full prescience of all the events in the operation, or even the
ability to guide the surgeon's hand, unless the patient also happened to be

33
a surgeon. Although a typical patient might be able to recognize some acts
of gross malpractice, such as being stitched up with foreign bodies left
inside, the patient would not know the implications of most of what he or
she saw and would have no idea of how to improve the surgeon's
performance. For this reason, from the point of view of the patient, there
are no good alternatives to having trustworthy professionals. There are no
good alternatives in these circumstances because the patient must rely on
the discretion of the practitioner.
All physicians make mistakes, and most mistakes are not the result of
negligence. A physician may make a mistake because of an incomplete
knowledge base, an error in perception or judgment, or a lapse in attention.
Making decisions on the basis of inaccurate or incomplete data may lead to
a mistake. The environment in which physicians practice may also
contribute to errors. Lack of sleep, pressures to see patients in short
periods of time, and distractions may all impair an individual's ability to
avoid mistakes.
Two issues dominate the ethical concerns associated with mistakes
in medicine: disclosure and accountability. However, a third matter
deserves moral scrutiny: definitions of terms. We should to know what
counts as error before we can conclude who has a duty to reveal what
information, who has the right to receive information, and how professional
and legal systems should respond to misadventure.
Classic thinking about mistakes has focused on process and outcome.
People may proceed erroneously (begin the wrong operation, administer
the wrong medication, fail to do something prescribed or indicated) and,
through care or good luck prevent or escape harm. On the other hand,
things may expectedly work out poorly for the patient even though, upon
close examination, no one omitted appropriate actions, committed
inappropriate acts, or otherwise behaved wrongly. In many cases of
adverse outcome, one simply finds a great deal of uncertainty about what

34
happened and why. Medicine's lack of complete understanding of disease
and physiology leaves much unexplained or even inexplicable. At the very
least, despite human desire to eliminate doubt and fix blame, the world
of human medicine leaves a great deal up in the air when one wishes to
say a doctor, nurse, pharmacist, or other healthcare worker made an error
or that a system failed. Finding egregious behavior is easy; the problems
arise when an observer does not like what has happened but cannot
readily point a finger at the cause.
Starting in the last quarter of the twentieth century, attitudes and
practices towards disclosure of clear-cut medical error changed from
guild-like self-protectionism to more forthright, perhaps preemptive
truth-telling. That is, both medical ethicists and risk managers now
counsel practitioners to tell patients or their legally authorized
representatives (parents, guardians) when an obvious error occurs. Few
now suggest hiding an overdose, administration of a mismatched blood
product, or some clearly preventable difficulty in the operative field.
Philosophers and lawyers take a pragmatic approach here. Not only
people do want to know when something has gone wrong, not only
some argue wronged individuals have a right to know, the consequences
of failed cover-ups include overwhelming anger and much larger jury
awards. As Sissela Bok pointed out in «Lying: Moral Choice in Public
and Private Life», in a socially complex world, including that of modern
medicine, lying just does not succeed.
Note, however, that the generally accepted admonition to tell the
truth often fails to provide practical help. Did the surgical assistant pull
too harden the retractor, resulting in a lacerated artery and a much-
prolonged operation for microvascular repair? Was this negligence or
something about the patient's fragile tissues? If the patient's recovery is
unimpeded, does it matter? Do patients and surrogates want to know every
detail of what happened? Might full disclosure inappropriately undermine

35
trust? While there might be objective agreement that the degree of
disclosure should somehow follow the desires or psychological needs of
patients, loved ones, and legal surrogates, it is not at all clear how one
determines, in advance, how much an individual or family member wants
to know in a given situation.
Regarding accountability, many problems remain. If the assistant in
the hypothetical operation was a surgical intern scrubbing in on this kind
of operation for the first time, how does that fact influence an assessment
of whether she made a culpable mistake or made an excusable error? The
legal system usually acknowledges that trainees do not bear the same level
of responsibility as their supervisors—much of the time lawsuits drop
involved students and residents from being named defendants in
malpractice actions. However, there are no reliable systems for
determining how professionals or society should factor (in)experience into
judgments about moral responsibility for things going awry.
At the end of the twentieth century, mistakes in medicine began to
receive attention appropriate to their contribution to morbidity and
mortality in the healthcare system. Public policy began to concentrate on
recurring, systematic underlying causes of medical error and borrow
concepts from cognitive science, social psychology, and organizational be-
havior to address the pervasive problem of medical mistakes. Whether this
approach to improving patient’s safety will reduce the incidence or
seriousness of medical error remains to be seen, especially as industrial
thinking has not paid close attention to the actual and powerful culture of
medicine. Also unclear is the effect that an impersonal line of attack on the
problem will have on professional morality. Too great an emphasis on
technical fixes may erode the sense of personal ethical obligation to
patients that society wants its healthcare professionals to hold dear.

36
 ABORTION
I. The Definitions of Pregnancy, Miscarriage and Abortion.
II. The Main Positions for Abortion.
III. Religion and Cultural Attitudes to Abortion.

Literature
Steven Schwartz. The Moral Question of Abortion. Loyola University
Press, 1990.
Don Marquis. «An Argument that Abortion is Wrong» In: John Arthur
(ed.) Morality and Moral Controversies, 5th Ed. Upper Saddle River, NJ:
Prentice Hall, 1999.
Jennifer A. Hurley. The Ethics of Abortion. Greenhaven Pr, 2000.
Robert M. Baird, Stuart E. Rosenbaum (ed.). The Ethics of Abortion.
Prometheus Books, 2001.

Reports, synopses, course and term paper

The Moral Status of Pre-embryo, Embryo and Fetus.
Different Religions on Abortion.
Abortion in India, Malaysia and African Countries.
Abortion Law.

Pregnancy is the process by which a woman carries a live offspring

from conception until it develops to the point where the offspring is
capable of living outside the womb. It starts with conception, the process
of fertilization to form zygote, and ends in childbirth, miscarriage, or
abortion. Miscarriage is the natural or accidental termination of a
pregnancy at the stage where the fetus is incapable of surviving.
Miscarriages can occur for many reasons, not all of which can be
identified. Abortion is voluntary or induced termination of pregnancy.
A number of serious ethical questions is raised by the practice of

37
abortion. The question of the moral permissibility of abortion demands
that we answer two very hard philosophical questions. The first requires us
to consider which traits of developing fetus are relevant to deciding what
morally may and may be done to it. The general problem discussed in this
case is often called «the problem of the status of the fetus». The second
question that demands our attention can be classified as «the problem of
the conflict of claims».
The problem of the status of the fetus can be formulated as follows:
At what stage, if any, of their development do fetuses become people? A
variety of familiar answers have been given — for example, the fetuses
become persons «at the moment of conception», at «quickening» (that is,
when the fetus is able to movement in the womb), at viability (that is,
when the fetus is able to survive independently outside the mother’s
womb). Debates about when the fetus becomes a person, however, are
premature unless we have first explored what a person is. An answer to the
question «When does the fetus become a person?» attempts to draw a
boundary line between prepersons and persons; however, even if correctly
drawn, a boundary line is not the same thing as a criterion of personhood.
The fetus at all stages is obviously human in genetic sense, but that is
not the sense of the term intended in the moral rule against homicide. For
a genetically human entity to have a right to life it must be a human being
in the sense of a person. But the term «person» is ambiguous. In the
common sense of the descriptive meaning of the term, it refers to any
being of any species or category who has certain familiar characteristics,
of which consciousness of the world, self-concepts, and the capacity to
plan ahead are prominent. In the purely normative (moral or legal) sense, a
person is any being who has certain rights and/or duties, whatever his
other characteristics are. Whether or not abortion is homicide depends on
what the correct criterion of moral personhood is.
Even if we were to grant that the fetus is a moral person and thus has

38
a valid claim to life, it would not follow that abortion is always wrong. For
there are other moral persons, in addition to the fetus, whose interests are
involved. The woman in whose uterus the fetus abides, in particular, has
needs and interests that may well conflict with brining the fetus to term.
Do any of these needs and interests of the woman provide grounds for her
having a genuine claim to an abortion and, if they do, which of the two
conflicting claims — the woman’s claim to an abortion or her fetus’s claim
to life — ought to be respected if they happen to conflict?
The right to an abortion that is often claimed on behalf of all women
is a discretionary right to be exercised or not, on a given occasion, as the
woman sees fit. For that reason it is sometimes called a «right to choose».
Right to an abortion can only be understood by reference to other, more
fundamental rights from which it has often been claimed to be derived.
Three of these rights and their possible association with the right to an
abortion deserve our closest scrutiny. There are some previously
mentioned property rights: the right to self-defense, and the right to bodily
autonomy.
Conventionally in modern bioethics we can find three main positions for
abortion:
Liberal. It is permissive point of view on abortion, according to it a
woman can control her body and decide about abortion.
Medium point of view says that embryo gradually accumulates the
quality of a human being. We must regard the balance of interests of a
woman and the embryo in each trimester individually.
Conservative. It is a point of view on abortion, according to which
abortion is willful murder. An offspring is an individual from conception
and it has natural rights of a man.
Abortion is a controversial ethical issue in many countries and
religions. The anthropologists demonstrate that abortion had been
practised in almost all human communities from the earliest times. The

39
patterns of abortion use, in hundreds of societies around the world since
before recorded history, have been strikingly similar. Women faced with
unwanted pregnancies have turned to abortion, regardless of religious or
legal sanction and often at considerable risk.
In primitive tribal societies, abortions were induced by using poisonous
herbs, sharp sticks, or by sheer pressure on the abdomen until vaginal
bleeding occurred. Abortion techniques are described in the oldest known
medical texts. The ancient Chinese and Egyptians had their methods and
recipes to cause abortion, and Greek and Roman civilizations considered
abortion an integral part of maintaining a stable population. Ancient
instruments, such as the ones found at Pompeii and Herculaneum, were
much like modern surgical instruments. Socrates, Plato and Aristotle were
all known to suggest abortion. Roman morality placed no social stigma on
abortion.
Early Christians condemned abortion, but did not view the
termination of a pregnancy to be an abortion before «ensoulment», the
definition of when life began in the womb. Up to 400 AD., as the
relatively few Christians were widely scattered geographically, the actual
practice of abortion among Christians probably varied considerably and
was influenced by regional customs and practices. Early Christian
theologians believed, as had Aristotle centuries before, that «animation»,
or the coming alive of the fetus, occurred forty days after conception for a
boy and eighty days after conception for a girl. The conclusion that early
abortion is not homicide is contained in the first authoritative collection of
canon law accepted by the church in 1140.
At the beginning of the 13th century, Pope Innocent III wrote that
«quickening» —the time when a woman first feels the fetus move within
her— was the moment at which abortion became homicide; prior to
quickening, abortion was a less serious sin. The tolerant approach to
abortion which had prevailed in the Roman Catholic Church for centuries

40
ended at the end of the nineteenth century. In 1869, Pope Pius IX
officially eliminated the Catholic distinction between an animated and a
nonanimated fetus and required excommunication for abortions at any
stage of pregnancy. This change has been seen by some as a means of
countering the rising birth control movement, especially in France and
Italy. During the latter part of the nineteenth century, European views on
the restriction of abortion were spread by the colonial powers throughout
Africa, Asia and beyond. The strict prohibitions of Spain are reflected in
many statutes decreed in South America, for example. Toward the end of
the 19th century, China and Japan, at the time under the influence of
Western powers, also criminalized abortion for the first time. The Soviet
Union (1920) and Iceland (1935) were some of the first countries to
generally allow abortion. The second half of the twentieth century saw the
liberalization of abortion laws in many other countries. Abortion is legal,
accepted and even sometimes encouraged in China, India and other
populous countries. At present almost two-thirds of the world’s women
reside in countries where abortion may be obtained on request or for a
broad range of social, economic or personal reasons. Liberalization has
been successful; countries which have developed access to safe, legal
abortion have typically lowered the rates of pregnancy-related
complications and death as well as infanticide, and improved the health of
women and their families. In all European countries except for three (the
Irish Republic, Northern Ireland and Malta), induced abortion is legally
available at least for some reasons. Since 1957, China has had one of the
most open abortion policies in the world. Abortion is free upon the request
of the woman. In 1979, because of concerns over the country's high rate of
population growth, the Chinese government began implementing its harsh
«one-child policy». The one-child policy mandates that couples have no
more than one child in urban areas, while rural families may have up to
two children in very limited circumstances. The situation in India shows

41
that legalizing abortion does not ensure that it becomes accessible.
Legal abortion was introduced in 1971, when concern about
burgeoning population growth became an issue for India. Although
abortion is legal, it is estimated that a power of people Indian women still
resort to illegal abortions because of social taboos, misconceptions about
the law, and the lack of skilled practitioners and medical facilities. In
Malaysia a restrictive law was replaced. It allows abortion if continuing a
pregnancy involves more risk to the woman’s physical or mental health
that terminating it.
Many religions place legal or moral limitations on active abortion,
for various theological reasons. Judaism holds when the fetus is not yet a
full human being, killing a fetus is not a murder. Abortion, when
necessary, takes place before the first forty days, when the fetus is referred
to as a «mere water». Abortion for therapeutic reasons, when the woman’s
life is clearly in danger, is mandatory in Judaism. Her life takes absolute
precedence over the potential life of the fetus, which is not regarded as full
life until late in the process of birth.
Each of the major denomination of Christianity has much to say,
because the view that life begins at conception is a controversial one. This
may be a difficult problem, as the relatively recent view that life begins at
conception, versus the traditional view that it begins at quickening, that is
the time than fetus movements are first felt by the mother.
The official Catholic view, articulated in Humanae Vitae, shared by
some other Christians, is that human life begins at conception and that
abortion is therefore a murder. The Church considers abortion intrinsically
evil and never morally acceptable. Catholics who procure or participate in
an abortion incur automatic excommunication.
Protestant views on abortion vary considerably. In Evangelical
churches, especially in the United States, the view is widely held that
abortion is infanticide and therefore always wrong. Lately many

42
Evangelical churches have encouraged their congregations to only vote
pro-life. The Bible contains many specific prohibitions to abortion. Both
the Old and New Testament contains several passages that clearly indicate
that life begins at conception, in which case a ban on abortion follows
logically. Few Protestant churches agree with the principle of «abortion on
demand». More liberal protestants usually agree that there should be
restrictions on abortion, and disagree over exactly what those restrictions
should be.
The majority of Muslim scholars permit abortion, although they
differ on the stage of fetal development beyond which it becomes
prohibited. Scholars agree that abortion at or after the ensoulment stage is
prohibited, except to save the woman’s life.
Buddhists characterize all forms of life (including animals) as
«sentient beings». A fertilized egg is considered a sentient being, and
abortion is synonymous with killing.

MODERN REPRODUCTIVE TECHNOLOGIES

I. Artificial Insemination.
II. In Vitro Fertilization.
III. Surrogate Mother.
IV. Basic Bioethic Principles Related to Modern Reproductive
Technologies.

Literature
Boggs, William M., and Rosella D. Smith. The Journey to Fertility: A
Couple's Guide to In Vitro Fertilization. Timonium, MD: Wilrose Books,
2001.
Buchanan AE, Brock DW. Deciding For Others: The Ethics of Surrogate
Decision Making. New York: Cambridge University Press, 1990.
DeJonge, Christopher J. Assisted Reproductive Technologies: Current

43
Accomplishments and New Horizons. Oxford: Cambridge University
Press, 2002.
Elder, Kay, and Brian Dale. In Vitro Fertilization, 2nd edition. Oxford:
Cambridge University Press, 2000.
Trounson, Alan O., and David K. Gaardner. Handbook of In Vitro
Fertilization, 2nd edition. Boca Raton, FL: CRC Press, 1999.

Reports, synopses, course and term paper

Psychological Problems of Surrogate Mother.
Artificial Insemination: Moral Dilemmas.
Religions and Modern Reproductive Technologies.
Ethical Considerations for Sperm Donation.

Modern reproductive technologies are most disputable nowadays.

Many of the problems of modern reproductive technologies are moral and
juridical. Today the most widely used reproductive technologies are:
artificial insemination, in vitro fertilization, surrogate mother.
Artificial insemination (AI) is when sperm is placed into a female's
uterus using artificial means rather than by sexual intercourse. Semen
from the father or donor is injected directly into woman uterus to improve
the chance of conception in the process called intrauterine insemination.
Many people think of artificial insemination as a modern technology
but it has a long history. More than 100 years later in 1780 an Italian priest
and physiologist named Lazzaro Spallanzani performed a successful
experiment on dogs in his laboratory. Although the artificial insemination
of animals was quickly formed into an industry, the application of this
technology to the growth of humans babies proceeded slowly.
Artificial insemination is usually part of an infertility treatment.
Infertility is the inability of a couple to naturally conceive, carry or deliver
a healthy child. The International Council on Infertility Information

44
Dissemination (INCIID) considers a couple to be infertile if they have not
conceived "after a year of unprotected intercourse in women under 35, or
after six months in women over 35" or if they are incapable of carrying a
pregnancy to term. We can identify two types of artificial insemination:
— artificial insemination by husband. AIH, homologic insemination
means the use of husband’s sperm
— artificial insemination by donor, AID or heterologic can use
donor`s sperm.
In artificial insemination, the child is carried to term in the uterus of
the mother.
Artificial insemination has become a significant issue in recent years,
particularly in debates revolving around surrogate parenting. If compared
to heterologic, homologic insemination doesn`t contradict moral and
family norms and principles, while heterologic insemination. It is rather
disputable, as a donor may conceive his sexual and psychic defects,
familial diseases. Furthermore, child may know that his genetic father is an
unknown man and this will bring to the crisis of identity.
One more modern reproduction technique is in vitro fertilization
(IVF). It is a technique in which eggs are fertilized outside the woman's
body. IVF is a major treatment in infertility when other methods of
achieving conception have failed. The process involves hormone
controlling the ovulatory process, removing ova (eggs) from the woman's
ovaries and letting sperm fertilize them in a fluid medium. The fertilized
egg (zygote) is then transferred to the patient's uterus with the intent to
establish a successful pregnancy.
«In vitro» is Latin for «in glass», referring to the test tubes, however
neither glass nor test tubes are being used; the term is used generically for
laboratory procedures.
This technique was developed in the United Kingdom by Doctors
Patrick Steptoe and Robert Edwards. The first so-called «test-tube baby»,

45
Louse Brown, was born on July, 1978 amid intense controversy over the
safety and morality of the procedure. The first in-vitro fertilization (to
produce test tube baby «Durga») in India (and second in the world) was
performed on October, 1978.
Now IVF has exploded in popularity, with as many as 1% of all
births being conceived in-vitro. Initially the IVF was developed to
overcome infertility due to problems of the fallopian tubes, but it turned
out that it was successful in most other infertility situations as well. The
chance of a successful pregnancy is approximately 20-30 per cent for each
IVF cycle. There are many factors that determine success rates including
the age of the patient, the quality of the eggs and sperm, the duration of the
infertility, the health of the uterus, and the medical expertise. It is a
common practice for IVF programs to boost the pregnancy rate by placing
multiple embryos during embryo transfer. A flip side of this practice is a
higher risk of multiple pregnancy, itself associated with obstetric
complications. IVF programs generally publish their pregnancy rates,
however comparisons between clinics are difficult as many variables
determine outcome. Furthermore, statistics depends strongly on the type of
patients selected.
The major complication of IVF is the development of multiple births.
This is directly related to the practice of placing multiple embryos in
embryo transfer. Spontaneous splitting of embryos in the womb after
transfer does occur, but is rare (<1%) and would lead to identical twins.
Another major complication, related to the use of ovarian stimulation is the
development of the ovarian hyperstimulation syndrome.
Certain ethical issues have been raised from the beginning when IVF
was introduced. These concerns include:
 Bypassing the natural method of conception.
 Creating life in the laboratory.
 Fertilizing more embryos than will be necessary.

46
  Discarding excess embryos.
 Unnatural environment for embryos.
 Using untested technology.
 Disallocation of medical resources.
 Contribution to overpopulation.
 Creating embryos, freezing them, and keeping them "in limbo".
 Exposing embryos to unnatural substances.
 Destroying embryos in research.
 Potential to create embryos for medical purposes.
 Potential to select embryos.
 Potential to modify embryos.
Separating the traditional mother-father model is one more problem.
To achieve a pregnancy can be provided by a third party or more parties.
This has created additional ethical and legal concerns. The use of IVF
provides also greater range of options for single people and same-sex
couples wishing to have children. Although both groups already raise
children, IVF facilitates this process. Some people object, saying that this
could give psychological problems to the child if they grow up without a
mother/father role-model.
IVF programs in many countries are subjected to regulations that
regulate many aspects of IVF practice. In such settings regulations may
dictate:
 The number of oocytes that can be fertilized.
 The number of embryos that can be transferred.
 The use of cryopreservation.
 The use of third party reproduction.
 The ability to perform tests or interventions on the embryo.
A surrogate mother or ersatz mother is a woman who carries a child
for a couple or single person with the intention of giving that child up once

47
it is born. The surrogate mother may be the baby's biological mother
(traditional surrogacy) or she may be implanted with someone else's
fertilized egg (gestational surrogacy). The most common reason for using
a surrogate mother is infertility. Gay male couples have also used
surrogate mothers in order to have children that at least one partner is
biologically related to. Legal issues have arisen in cases where the
surrogate mother decides to keep the child. Likewise, there have been
debates over the rights of sperm donors.
The most famous case of surrogacy the case, in which the surrogate
mother refused to surrender the child she had born to the child's biological
father. Baby M was the name given to the child in an American custody
case between the surrogate mother hired to carry her, and the child’s
biological father. Mary Beth Whitehead, the surrogate mother, was
artificially inseminated with William Stern’s sperm. Contrary to popular
belief (as well as what was stated in the surrogacy contract), Mr. Stern’s
wife, Elizabeth, was not infertile, but rather there was a possibility she had
multiple sclerosis. On March, 1986, Whitehead gave birth to a daughter,
who she named «Sara Elizabeth Whitehead», and refused to give her up to
the Sterns. A New Jersey court awarded custody of Melissa (as the Sterns
had named her) to the Sterns in 1987, but this ruling was overturned by the
Supreme Court of New Jersey on February, 1988. The Supreme Court
remanded the case to family court. On remand, the lower court awarded
William Stern custody and Mary Beth Whitehead visitation rights. The
case attracted much attention as it demonstrated that the possibilities of
third party reproduction had novel legal and societal ramifications. The
case exposed the dilemma of a birth mother created by contractual
agreements and biological bonding. The case also split feminists who on
one hand argued that a woman has a right over her body and on the other
hand were sensitive to the issue of exploitation. The surrogacy
arrangement was heavily criticized.

48
Bioethicists often refer to the four basic principles of health care ethics
when evaluating the merits and difficulties of medical procedures.  Ideally,
for a medical practice to be considered «ethical», it must respect all four of
these principles: autonomy, justice, beneficence, and nonmaleficence.  The
use of reproductive technology raises questions in each of these areas.
The principle of nonmaleficence requires that a procedure does not
harm the patient involved or others in society.  Infertility specialists
operate under the assumption that they are doing no harm or at least
minimizing harm by pursuing the greater good.  However, because
assistive reproductive technologies have limited success rates uncertain
overall outcomes, the emotional state of the patient may be impacted
negatively.  In some cases, it is difficult for doctors to successfully apply
the «do no harm principle».
The principle of beneficence requires that the procedure is provided
with the intent of doing good for the patient involved.  Demands that
health care providers develop and maintain skills and knowledge,
continually update training, consider individual circumstances of all
patients, and strive for net benefit.
The principle of respect for autonomy requires that the patient has
autonomy of thought, intention, and action when making decisions
regarding health care procedures.  Therefore, the decision-making process
must be free of coercion or coaxing.  In order to make a fully informed
decision, a patient must understand all risks and benefits of the procedure
and the likelihood of success.  Because ARTs are highly technical and may
involve high emotions, it is difficult to expect patients to be operating
under fully-informed consent.
The principle of justice claims the idea that the burdens and benefits
of new or
experimental treatments must be distributed equally among all groups in
society. It requires that procedures uphold the spirit of existing laws and

49
are fair to all players involved.  The health care provider must consider
four main areas while evaluating justice: fair distribution of scarce
resources, competing needs, rights and obligations, and potential conflicts
with established legislation.  Reproductive technologies create ethical
dilemmas because treatment is not equally available to all people.

50
 EUTHANASIA
I. The Definition and Classification of Euthanasia.
II. Euthanasia: Pros & Cons.
III. Legislation and National Political Movements.

Literature
J. Keown. Euthanasia, ethics and public policy: an argument against
legalization. New York: Cambridge University Press, 2002.
H. Kuhse. The Sanctity-of-Life Doctrine in Medicine: A Critique. Oxford:
Clarendon Press, 1987.
J. McMahan. The Ethics of Killing: Problems at the Margins of Life. New
York: Oxford University Press, 2002.
J. Rachels. The End of Life: Euthanasia and Morality. Oxford: Oxford
University Press, 1986.

Reports, synopses, course and term paper

The Physicians` Attitude to Euthanasia.
Attitudes to Euthanasia in Malaysia and other Asian Countries.
Euthanasia and Other End-of-Life Decisions in the Netherlands.
Religious Aspects of Euthanasia.

In most Western societies, the Judeo-Christian religious tradition has

given great importance to the sanctity of life. Modern medicine has also
gained extraordinary new powers to prolong life. Within the last few
decades, medical treatments such as kidney dialysis, cardiopulmonary
resuscitation, organ transplantation, respirator support, and provision of
food and water by artificial means have become common in hospitals. The
ethics of euthanasia has been the subject of intense discussion throughout
the world.
The term Euthanasia originated from the Greek language: «eu»

51
means «good» and «thanatos» means «death». One meaning given to the
word is «the intentional termination of life by another person at the explicit
request of the person who dies».
It is common practice to differentiate some forms of euthanasia.
Passive euthanasia is usually defined as withdrawing medical
treatment with the deliberate intention of causing the patient's death. For
example: removing life support equipment (e.g. turning off a respirator) or
stopping medical procedures, medications etc., or stopping food and water
and allowing the person to dehydrate or starve to death. Not delivering
CPR (cardio-pulmonary resuscitation) and allowing a person, whose heart
has stopped, to die.
Active euthanasia occurs when one person performs the act of ending
another person's life.  An example of this may be a nurse injecting the
lethal dose of a substance into a person's vein with the intention to end that
person's life. So, the difference between «active» and «passive» is that in
active euthanasia, something is done to end the patient's life; in passive
euthanasia, something is not done that would have preserved the patient's
life.
We may also classify euthanasia as:
— Voluntary euthanasia — it is when a clearly competent person
makes a voluntary and enduring request to be helped to die.
— Non-voluntary euthanasia — instances of euthanasia where a
person is either not competent to, or unable to express a wish about
euthanasia and there is no one authorised to make a substituted judgment.
— Involuntary euthanasia, where a competent person's life is brought
to an end despite an explicit expression of opposition to euthanasia,
beyond saying that, no matter how honourable the perpetrator's motive is,
such a death is, and ought to be, unlawful.
Besides these types we define «assisted suicide», a doctor provides a
patient with the means to end his own life (e.g. a prescription for lethal

52
dose of sleeping pills), but the doctor does not administer it.
Debate about the morality and legality of voluntary euthanasia has
been, for the most part, a phenomenon of the second half of the twentieth
century and the beginning of the twenty first century. Several factors have
contributed to the increased interest to euthanasia. In 1988 there was an
unsuccessful attempt to get the question of whether it should be made
legally permissible on the ballot in California. In addition to some cases of
this kind, such as «It's Over, Debbie», described in the Journal of the
American Medical Association, the «suicide machine» of Dr. Jack
Kevorkian, and the cancer patient «Diane» of Dr. Timothy Quill, have
captured wide public and professional attention.
The central ethical argument for euthanasia — the respect for persons
demands respect for their autonomous choices as long as those choices do
not result in harm to others — is directly connected with this issue of
competence, because autonomy presupposes competence. People have
interest in making important decisions about their lives in accordance with
their own conception of how they want their lives to go. In exercising
autonomy or self-determination, people take responsibility for their lives;
since dying is a part of life, choices about the manner of their dying and
the time of their death are, for many people, part of what is involved in
taking responsibility for their lives. Many people are concerned about what
the last phase of their lives will be like, not merely because of fears that
their dying might involve them in great suffering, but also because of the
desire to retain their dignity and as much control over their lives as
possible during this phase.
The technological interventions of modern medicine have had the
effect of stretching out the time it takes for many people to die. Sometimes
the added life brings is an occasion for rejoicing; sometimes it drags out
the period of significant physical and intellectual decline that a person
undergoes in burdensome ways so that life becomes, to them, no longer

53
worth living. It is the second argument which points up the importance of
individuals being able to decide autonomously for themselves whether
their own lives retain sufficient quality and dignity to make life worth
living. One objection to euthanasia is that it involves killing, and all killing
is morally wrong. This principle may be based on religious views (e.g., the
sixth commandment) or maintained by purely secular grounds. Euthanasia
violates some duty to God, or to ourselves, or to others.
The next group of argumentation supposes that there is always the
possibility of an incorrect diagnosis or the discovery of a treatment that
will permit either survival or recovery. We can never be absolutely sure
that we have voluntary and informed consent. If the request is made prior
to patients' coming to be in a desperately bad way — say in the form of a
living will — it cannot be considered binding because it is insufficiently
informed. On the other hand, if the request is made when patients are in a
bad way, then the pain and drugs prevent them from making a fully
rational decision. In either case, it is not possible to secure a death-request
which would justify it.
The chronically and terminally ill are often vulnerable and feel
themselves to be (and often are) a burden to others. Many of the ill,
however, are not tired of life and do not want to die. But if assisted suicide
and active voluntary euthanasia were readily available, they might feel
obligated to ask for death, and relatives or others in whose care they are,
who often would just as soon get rid of the burden, may consciously or
unconsciously exert pressures, in a way difficult to detect and avoid, to
request assistance in committing suicide or active voluntary euthanasia.
Legalizing assisted suicide and active voluntary euthanasia today will
lead to active non-voluntary euthanasia tomorrow, and that will lead to
active involuntary euthanasia the day after: the antisocial, the ethnically
unattractive, the politically deviant, the aged, etc., will all become
potential victims. Thus if we do not draw the line where it is, we will not

54
be able to prevent substantial harm to others. This is the famous slippery
slope argument.
The medical profession exists to provide important professional
services, and neither wants to be nor should be involved in the kind of
bureaucratic activity involved in responsibly administering the delivery of
assisted suicide and active voluntary euthanasia. The legalization of
assisted suicide and active voluntary euthanasia will discourage the search
for new cures and treatments for the terminally ill patient.
Patients who struggle to recover have better recovery rates than those
who have given up hope. The availability of assisted suicide and active
voluntary euthanasia will encourage patients to give up, and thus
significantly decrease their chances for recovery.
The Netherlands has become the first country in the world to legalize
euthanasia. In The Netherlands  the Termination of Life on Request and
Assisted Suicide Act, legalizes euthanasia and physician-assisted suicide
in certain circumstances. In the Netherlands the guidelines were
established to permit physicians to practise voluntary euthanasia in those
instances in which a competent patient had made a voluntary and informed
decision to die, the patient's suffering was unbearable, there was no way of
making that suffering bearable that was acceptable to the patient, and the
physician's judgments as to diagnosis and prognosis were confirmed after
consultation with another physician.
Euthanasia was legalised in Australia’s Northern Territory, by the
Rights of the Terminally Ill Act 1995. However, this law was soon made
ineffective by an amendment by the Commonwealth government to the
Northern Territory (Self-Government) Act 1978. (The powers of the
Northern Territory legislature, unlike those of the State legislatures, are not
guaranteed by the Australian Constitution.)
After an extensive discussion the Belgian parliament legalised
euthanasia in late September 2002. The new legislation, however,

55
institutes a complicated process, which has been criticized as an attempt to
establish a bureaucracy of death. Nevertheless, euthanasia is now legal and
its proponents in the country hope that it will stop many illegal practiceсes.
In Oregon in the United States, legislation was introduced in 1997 to
permit physician-assisted suicide after a second referendum clearly
endorsed the proposed legislation. Later in 1997, the Supreme Court of the
United States ruled that there is no constitutional right to physician-
assisted suicide; however, the Court did not preclude individual states
from legislating in favor of physician-assisted suicide. The Oregon
legislation has, in consequence, remained operative and has been
successfully utilized by a number of people.

SUICIDE
I. The Definition of Suicide.
II. Causes of Suicide.
III. Suicide: Philosophical Views.
IV. Suicide: Religious Views.

Literature
Durkheim Emile. Suicide: A Study in Sociology. New York: Free Press,
1966.
Tom L. Beauchamp. Suicide, in Matters of Life and Death. McGraw-Hill,
Inc, 1986.
Hume D. «On Suicide». Reprinted widely.
Joiner, Thomas E. Why People Die by Suicide. Cambridge, MA: Harvard
University Press. 2006.
Jamison, Kay Redfield. Night Falls Fast: Understanding Suicide. Vintage.
2000.
Minois. G. History of Suicide: Voluntary Death in Western Culture.
Baltimore: Johns Hopkins University Press. 1999.

56
 Reports, synopses, course and term paper
Libertarian Views and the Right to Suicide
Suicide and Morality: Theories of Plato and Kant.
Ethics of Suicide in Modern Time.
Suicide and Euthanasia: Historical and Contemporary Themes.
Kant and the Irrationality of Suicide.

Suicide is a fact of everyday life. According to the World Health

Organization, it can be reasonably estimated that (in reporting nation)
about 1,000 people commit suicide every day. Moreover, the persons most
knowledgeable about problems of suicidal patients commit suicide more
often than any other segment of the population. The physician suicide rate
is variously estimated at two to three times the rate of the general
population, and the rate for psychiatrists increases to two - three times that
of the physicians.
Suicide present unresolved moral problems about the value of life.
Philosophers have talked about the moral permissibility or
impermissibility of suicide at least since Plato and Aristotle, and several
major writings on suicide have been bequeathed to us from major figures
in the history of philosophy. There are at least two reasons why interest in
the morality of suicide has increased in recent years. First, biomedical
technology has made it possible for ill and seriously injured persons to
prolong their lives beyond the point at which, in former times, they would
have died. Many of these patients are seriously sick and agony. Numerous
people have come to think that suicide is justified in such cases, even that
those who are incapacitated should be assisted in their acts of suicide.
Slogans such as «the right to die» and «death with dignity» have grown up
around such cases. Second, although suicide laws have been repealed,
repeal is a matter of present debate. Whether «assisted suicide» should be
decriminalized is also under active discussion. These debates turn more on

57
moral than legal considerations.
In recent years, three definitions have been widely accepted as ways
of understanding suicide. The first is simple and might be called the
prevailing definition: suicide occurs if and only if there is an intentional
termination of one`s life. Contemporary moral philosophers such as R.B.
Brandt and Eike-Henner Kluge have employed similar definitions, and this
definition also is found in Gould`s Medical Dictionary and Encyclopedia
of Bioethics. The second definition, by contrast, supposedly does not rely
on the intent to terminate life and derives from the sociologist Emile
Durkheim: The term suicide is applied to all cases of death resulting
directly or indirectly from a positive or negative act of the victim himself,
which he knows will produce this result. The word «know» in Durkheim`s
definition seems objectionable to those who support this definition,
because the suicidal person may not know that a given act or life-style will
produce death. Among fifteen-to twenty-four-year-olds, suicides are the
second leading killer, behind traffic accidents. Yet many suicidologists and
police authorities believe that these traffic «accidents» are often the result
of suicidal gambles or are disguised suicides. Because such persons are not
clearly suicides according to either the first or the second definition, some
writers maintain that neither of the first two definitions should be
accepted; thus we get another reason for the third or omnibus definition.
As a contemporary sociologist Ronald Maris has stated it: Suicide occurs
when an individual engages in a life-style that he knows might kill him
(other than living another day) — and it does [kill him]. This is an
omnibus definition of suicide, which includes various forms of self-
destruction, such as risk-taking and many so-called «accidents». Erwin
Strengel, a contemporary psychiatrist, supports this third definition. He
contends that the majority of «suicides» have ambivalent intentions about
whether to take their lives and cannot correctly be said either to want to
live or to want to die.

58
 It is common practice to differentiate 3 groups of suicide: social,
political or cultural and religious.
Emile Durkheim categorized reasons for suicide. After careful
analysis Durkheim found it was the individual’s bonding to society that
could determine whether or not he was likely to commit suicide, and he
described four different types of these bonds:
Altruistic: Durkheim explained that too much social integration leads
to self-sacrifice for society, patriotism, honour. For instance, the WWII
kamikaze pilot, commits himself to a goal beyond himself and considers
this world an obstacle and burden.
Egotistic: Too little social integration leads to alienation, loneliness.
An egotist sees no goal to which he might commit himself, and thus feels
useless and without purpose.
Anomic: Whenever an economy is not regulated enough, conditions
such as unemployment or iniquitous distribution of wealth arise. Durkheim
believed that it is the role of the society to regulate the economy, and he
sees the relationship between a society’s suicide rate and the way it
performs this important regulative function.
Fatalistic: When society sets economic expectations too high,
individuals who fail to meet these standards can lose all sense of self-
worth.
Contemporary authors suggest modern social reasons for suicide: 1.
Domestic violence. 2. Bullying. 3. Physical disability. 4. Racism. 5. Rape.
6. Divorce.
Examples of cultural «altruistic» suicide include the Indian custom of
suttee where widows (but not widowers) burn themselves to death.
Japanese seppuku or hara-kiri where ritual disembowelment prevents, or
atones for dishonour. Among military officers in nineteenth-century
Europe suicide-by-pistol was the expected response to inability to pay
gambling depts. Suicide by groups seeing themselves as persecuted also

59
falls into this category; the Branch Davidians (Waco, Texas, 1993) for
example, or the members of the People’s Temple at Jonestown (Guyana,
1978), who held suicide «rehearsals».
Sometimes there are extraordinary or temporary circumstances that
lead to a high suicide rate. In the 1990s Sri Lanka, in the midst of a
protracted civil war, has had unusually high rates.
Suicide attacks have become the defining act of political violence of
our age. Since 1981, more than 30 organizations throughout the world —
some of them secular and others affiliated to radical Islam — have carried
out more than 600 suicide missions. Although a tiny fraction of the overall
number of guerrilla and terrorist attacks occurring in the same period, the
results have proved significantly more lethal.
Cult suicide is that phenomenon by which some religious groups, in
this context often referred to as «cults», have led to their membership
committing suicide. Sometimes all members commit suicide at the same
time and place. Groups which have done this include, Heaven’s Gate,
Order of the Solar Temple, Peoples Temple (Jonestown), Old Believers
and others.
St. Thomas Aquinas and David Hume are philosophers who can
illustrate the application of the ethical principle to the moral problems of
suicide. For both philosophers, arguments about the permissibility or
impermissibility of suicide have typically centered on questions of whether
suicide violates one or more of three obligations: to oneself, to others, and
to God.
During the medieval period, many arguments using a theological
basis were developed to demonstrate the immorality of suicide. These
arguments became the dominant view of the most influential theologians
of the Catholic church and of Orthodox Judaism, and they continue today
to exert powerful influence on the views of many religious persons. Their
arguments range from straight biblical injunctions against killing, as in the

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Sixth Commandment to the rather more reasoned philosophical arguments.
Aquinas advances three moral arguments against suicide in «Summa
Theologica»: 1) Suicide is contrary to natural self-love, whose aim is to
preserve us. 2) Suicide injures the community of which an individual is a
part. 3) Suicide violates our duty to God because God has given us life as a
gift and in taking our lives we violate his right to determine the duration of
our earthly existence. This conclusion was codified in the medieval
doctrine that suicide nullified human beings' relationship to God, for our
control over our body was limited to possession where God retained
dominium (dominion, authority). Law and popular practice in the Middle
Ages sanctioned the desecration of the suicidal corpse, along with
confiscation of property and denial of Christian burial.
David Hume in his essay «On Suicide» presented the strongest set
arguments for the moral permissibility of suicide in the classical history of
the subject. Where Christian theology has understood suicide as «an affair
between the devil and the individual sinner», Enlightenment philosophers
tended to conceive suicide in secular terms, as resulting from facts about
individuals, their natural psychologies, and their particular social settings.
Hume saw traditional attitudes toward suicide as muddled and
superstitious. According to the thomistic argument, suicide violates the
order God established for the world and usurps God's prerogative in
determining when we shall die. Hume's argument against this thesis is
intricate, as he tends to juxtapose distinguishable but closely related
considerations, but in essence Hume attacks the seemingly arbitrary and
contradictory notions of natural law used to condemn suicide. Hume's
argument is the following:
If by the «divine order» is meant the causal laws created by God,
then it would always be wrong to contravene these laws for the sake of our
own happiness. But clearly it is not wrong, since God frequently permits
us to contravene these laws, for he does not expect us not to respond to

61
disease or other calamities. Therefore, there is no apparent justification, as
Hume put it, for God's permitting us to disturb nature in some
circumstances but not in others. Just as God permits us to divert rivers for
irrigation, so he is also ought to permit us to divert blood from our veins.
If by «divine order» is meant the natural laws God has willed for us, which
are (a) discerned by reason, (b) such that adherence to them will produce
our happiness, then why should not suicide conform to such laws when it
appears rational to us that the balance of our happiness is best served by
suicide?
Finally if by «divine order» is meant simply that all occurs according
to God's consent, then God appears to consent to all our actions (since an
omnipotent God can presumably intervene in our acts at any point) and no
distinction exists between those of our actions to which God consents and
those to which He does not. If God has placed us upon the Earth like a
«sentinel», then our choosing to leave this post and take our lives occurs as
much with his cooperation as with any other act we perform.
Furthermore, suicide does not necessarily violate any duties toward
other people, according to Hume. Reciprocity may require that we benefit
society in exchange for the benefits it provides, but surely such reciprocity
reaches its limit when by living we provide only a «frivolous advantage»
to society at the expense of significant harm or suffering for ourselves. In
more extreme situations, we are actually burdens to others, in which a case
of our deaths is not only «innocent, but laudable».
Finally, Hume rejects the thesis that suicide violates our duties to
self. Sickness, old age, and other misfortunes can make life sufficiently
miserable that continued existence is worse than death. As to worries that
people are likely to attempt to take their lives capriciously, Hume replies
that our natural fear of death ensures that only after careful deliberation
and assessment of our future prospects we will have the courage and
clarity of mind to kill ourselves.

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In the end, Hume concludes that suicide «may be free of imputation of
guilt and blame». His position is largely utilitarian, allied with a strong
presumption of personal liberty.
For Buddhists, since the first precept is to refrain from the
destruction of life, including oneself, suicide is clearly considered a
negative form of action.
Early Christianity was attracted to death as martyrdom was
something they felt called upon by their faith to permit. As Christianity
became the dominant religion of the Roman empire, however, its views on
suicide changed, gradually. In the fifth century, St. Augustine wrote the
book «The City of God», in it making Christianity's first overall
condemnation of suicide. His biblical justification for this was his novel
interpretation of the commandment, «thou shalt not kill», and the rest of
his reasons were from Plato's «Phaedra». In the sixth century, suicide
became a religious sin and secular crime. In 533, those who committed
suicide while accused of a crime were denied a Christian burial, which was
a requirement for going to heaven. Many Christians believe in the sanctity
of human life, a principle which, broadly speaking, says that all human life
is sacred — a wonderful, even miraculous creation of the divine God —
and every effort must be made to save and preserve it whenever possible.
The essential context regarding the Catholic Church's condemnation
of suicide is the Church's absolute insistence on the sanctity of life. It is in
this regard, and taking into account the clear deliberation of the act by a
thinking person, that the Church regards suicide as being among the
gravest sins a person may commit and therefore creating the risk of eternal
damnation. The gravity of the Catholic Church's position resides in a
twofold argument:
1. Suicide is a rejection of God's love for mankind, and mankind's
love for God.
2. Suicide causes fracture to the social community of friends, loved-

63
ones and broader human society.
In Hinduism, murdering one's own body is considered equally sinful
as murdering another. Scriptures generally state that to die by suicide (and
any type of violent death) results in becoming a ghost.
Islam views suicide strictly as sinful and highly detrimental to one's
spiritual journey. According to the Sunnah (life and way of the Prophet
Muhammad), any person who dies by suicide and shows no regret for his
wrongdoing will spend an eternity in hell, reenacting the act by which he
took his own life.

PALLIATIVE CARE
I. Definition and Scope.
II. The Development of Palliative Care.
III. Ethical and Policy Issues in Palliative Care and Hospice.

Literature
Devine, Richard J. Good Care, Painful Choices: Medical Ethics for
Ordinary People. Mahwah, NJ: Paulist Press, 2004.
James Hallenbeck. Palliative Care Perspectives. New York: Oxford
University Press, 2003.
Joseph Fins A Palliative Ethic of Care. Boston Jones & Bartlett Pub, 2005.
Jonsen, Albert R. Bioethics Beyond the Headlines: Who Lives? Who
Dies? Who Decides. Lanham, MD: Rowman & Littlefield, 2005.
Mappes, Thomas A. and DeGrazia, David. Biomedical Ethics. Boston:
McGraw-Hill, 2006.
Purtilo, Ruth B. Ethical Dimensions in the Health Professions.
Philadelphia: Elsevier Saunders, 2005.

Reports, synopses, course and term paper

Hospice and Palliative Care History.

64
Ethical problems of Life-Sustaining Treatment.
Respect for Autonomy in Palliative Care.
Moral Values in Palliative Care.
The terms palliative care and hospice are frequently used
interchangeably to describe an approach to the care of individuals who are
likely to die in the relatively near future from serious, incurable disease, for
whom the principal focus of care is quality of life and support for the
patient's family. The terms gained currency in the last third of the
twentieth century as a result of significant changes in the leading causes of
death in the developed countries of the industrialized world. In these
countries prior to 1900, most people died relatively quickly, usually from
acute, infectious diseases. They typically died at home, attended by family
and friends. Because little in the way of medical technology was available
to prevent or delay death, the costs of care were low, and the dying person
and her caregivers could emphasize the interpersonal and spiritual aspects
of dying. By contrast, at the beginning of the twenty-first century most
people in the developed world die from chronic, degenerative diseases
such as cancer, cardiovascular disease, lung disease, and degenerative
neurological disease. Death usually follows a prolonged period of
progressive loss of function and numerous distressing symptoms, of which
pain and shortness of breath are the most feared by patients, along with
fear of the unknown. Because considerable medical technology now exists
that can postpone death, costs are often high and most people die in
hospitals or nursing homes, attended by strangers. For patients who die at
home, the financial, physical, and emotional burdens of caregiving fall
heavily on isolated nuclear families, and predominantly on women.
Hospital-based teams were created to provide care for patients in the
hospital units where they were still receiving treatment intended to cure
or slow the progress of their underlying disease. Things could also be
improved when people were being cared for at home, where most wanted

65
to remain as long as possible, though, contrary to what has always been
said, not necessarily to die there. A range of services was developed to
assist primary physicians caring for people at home, including home visits
by nurses and other professionals and day-care units for patients who
could be brought into a center for clinical assessment and creative
occupational therapy.
Palliative care was no longer synonymous with «care of the dying».
Yet, as the field has developed, it has struggled to define itself in a way that
captures its broader scope reflecting its appropriateness for patients
earlier in their disease process, who are not imminently dying-without
resorting to euphemisms chosen to disguise the fact that the care is for
people who, sooner rather than later, will die of their illness. The most
commonly used definition is that devised by the World Health
Organization. It emphasizes that the principles of palliation-the relief of
physical, psychosocial, and spiritual distress, and respect for the needs of
relatives— are appropriate from the time of diagnosis. In an attempt to
produce a more succinct definition, called for when palliative medicine
was recognized as a medical specialty in the United Kingdom in 1987,
palliative care was defined as the study and care of patients with active,
progressive, far-advanced disease and a limited life expectancy, for whom
the focus of care is the quality of life.
This definition does not limit palliative care to people with malignant
disease, nor does it state a prognosis in terms of months or weeks. It is
worded so as not to be confused with care of the elderly, care of the
chronically ill, or care of the incurable (which would embrace many of the
conditions seen daily by physicians). Unfortunately, it omits mention of
relatives, or the fact that palliative care can be provided only by an
interdisciplinary team. Its strength lies in its unequivocal focus on quality
of life rather than on cure or prolongation of life, the declared objectives
of much modern medical care.

66
 J. Andrew Billings, who reviewed many of the competing definitions,
concluded that the following definition achieves the best balance of
completeness and concision:
Palliative care is comprehensive, interdisciplinary care, focusing
primarily on promoting quality of life for patients living with a terminal
illness and for their families. Key elements for helping the patient and
family live as well as possible in the face of life-threatening illness include
assuring physical comfort, psychosocial and spiritual support, and
provision of coordinated services across various sites of care.
Two further statements, endorsed by the government of the United
Kingdom, have been found challenging and helpful:
It is the right of every person who needs it to receive high quality
palliative care, irrespective of his or her diagnosis.
It is the responsibility of every clinician to provide high quality
palliative care.
In applying these principles in the complex, highly differentiated
world of the health professions, it is helpful to note that palliative care can
be provided at three levels: principles, techniques, and specialist care.
Palliative care principles are integral to all good clinical care, and they
are applicable at every stage of a patient's care, whatever the nature of the
illness. Every doctor and nurse should apply these principles, even when
they are still defining the nature and cause of an illness or its symptoms.
From the handful in operation in 1967, there are now more than
6,200 palliative care programs in over 100 countries. In its birthplace, the
United Kingdom, palliative care services are readily and freely accessible
to all. The National Health Service runs one-fifth of these services, and 25
percent of the operating costs of the others are met by government, the
balance being met from voluntary funding. A typical palliative care in
patient unit in the United Kingdom, with 10 to 100 beds, admits annually
twenty to twenty-five patients per bed, where each will stay for an average

67
of eleven to fourteen days. The portion of patients able to return home
varies between 40 and 60 per cent, higher if there is an effective
community palliative care service and a day unit. Seldom do more than 15
per cent of patients who have conditions other than cancer receive
palliative care in the United Kingdom, a considerably smaller percentage
than in the United States.
Though palliative care services are being developed in many
countries, most are modeled on those of the United Kingdom and the
United States, rather than being designed to meet local needs and cultures.
Palliative care is still not available to the 75 per cent of the world's
population, for whom curative treatment of life-threatening disease is
either unavailable or inaccessible.
Many of the ethical issues that arise in the care of the dying are
similar to issues that arise in many other areas of healthcare, such as
truthfulness and confidentiality, decision-making authority in the
professional-patient relationship, the appropriate use and allocation of
technology and other healthcare resources. Other issues are more
commonly associated with the care of the terminally ill, though not absent
from other arenas, such as decision making for patients who have lost the
capacity to make or communicate their own decisions, withholding or
withdrawing life-sustaining treatment, and hastening death by assisting in
suicide or through active euthanasia.
The latter issue tends to receive the greatest attention from bioethics
scholars and policymakers. Moral distinctions between various actions or
choices that can hasten the time of death can be exquisitely fine. Yet, for
all the persistent and intense debate surrounding the issues of suicide and
euthanasia, «terminal sedation» and the doctrine of double effect, or the
differences, if any, between «allowing to die» and «causing to die»,
another set of issues are no less vexing and affect far more people. These
are the Questions of access to and quality of palliative care services. It is

68
true that dying at home is an imperfect marker for the adequacy of
palliative care. In fact, in most developed countries, the better the
palliative care provision in hospitals and the community, the fewer the
number of people who die at home, with home deaths now approaching
20 per cent in most European countries. A more telling statistic is that of
patients who received hospice care in 2000, one-third died within seven
days of admission, despite the six months of benefits allowed under the
Medicate hospice program. Although the reasons for these trends are still
being investigated, the following are likely to be significant contributing
factors: the difficulty of making precise estimates of life expectancy-as is
required for Medicate hospice eligibility- especially for diseases other than
cancer; patients' reluctance to accept the label «terminally ill»; the
requirement that patients forgo Medicare reimbursement for treatments
with curative intent; and many physicians identification of a hospice
referral with «giving up».
Worldwide, the challenge of access to competent palliative care is no
less daunting. Among the principal causes for alarm is the number of
people living with HIV/AIDS- estimated by the United Nations at 40
million at the end of 2001-and the large projected increase in deaths from
tobacco products, which the World Health Organization predicts could
triple by 2020 from the 2000 level of 3.5 million. In both cases, almost
all of the increase is expected to occur in the developing world. Global
efforts to teach the principles of modern palliative care, and to incorporate
them in healthcare systems, are lagging far behind the manifest need,
despite curative technologies and medications remaining unavailable or
unaffordable for most of the world's poor.
Where palliative care is available, there is the challenge of providing
care in ways that respect different cultural and religious views. Most
professionals who enter the field do so because they want to help people to
die well. But what does it mean to «die well»? What is a «good death»?

69
There is no single, universal answer to these questions. That modern
hospice movement was first promulgated largely by Christians may have
hindered its development among people of other faiths for whom the
«hospice philosophy» may have been hard to separate from theological
commitments that they did not share. Even with respect to elements of a
«good death» on which most people could probably agree — freedom from
pain, resolution of personal affairs, the supportive presence of loved ones-
there is a room for considerable personal variation. People differ in their
willingness to face the reality of their imminent death; in their desire to talk
about their feelings to friends, family, or caregivers; in how they balance
pain relief against alertness; and in their willingness to tolerate increasing
weakness, dependency, and uncertainty rather than trying to control the
timing and manner of their death through an act of suicide or euthanasia.
This variability requires health professionals to approach patients and
families as individuals, in an effort to provide care that is consistent both
with patient and family values and with their own conscience.

HOSPICE
I. The History of Hospice.
II. The Hospice Philosophy

Literature
James Hallenbeck. Palliative Care Perspectives. New York: Oxford
University Press, 2003.
Joseph Fins A Palliative Ethic of Care. Boston Jones & Bartlett Pub, 2005.
Purtilo, Ruth B. Ethical Dimensions in the Health Professions.
Philadelphia: Elsevier Saunders, 2005.
Jonsen, Albert R. Bioethics Beyond the Headlines: Who Lives? Who
Dies? Who Decides. Lanham, MD: Rowman & Littlefield, 2005.
Mappes, Thomas A. and DeGrazia, David. Biomedical Ethics. Boston:

70
McGraw-Hill, 2006.

71
Devine, Richard J. Good Care, Painful Choices: Medical Ethics for
Ordinary People. Mahwah, NJ: Paulist Press, 2004.

Reports, synopses, course and term paper

Palliative Medicine Approach to Caring for Patients with HIV/AIDS in
Hospice.
Palliative Medicine Approach to Caring for Pediatric Patients in Hospice.
International Association of Hospice and Palliative Care.
Hospice: Good Death or Good Life.

The word «hospice» stems from the Latin word «hospitium»

meaning guesthouse. It was originally used to describe a place of shelter
for weary and sick travelers returning from religious pilgrimages.
Each society throughout history has evolved special ways of caring
for the dying and the bereaved. For example: in old China the “death
houses” offered a place for the destitute dying to stay; in New Zealand,
Maori customs give practical support for the family at the time of death,
and encourage the community to participate in the mourning rituals; in
East Africa, wise elders give both practical and spiritual support to the
dying and bereaved.
In Western Europe and North America until the 19th Century, caring
for the dying and the bereaved was seen primarily as the job of the family
and the church. In the last 100 years, dying has increasingly been seen as a
medical event, not as a milestone in the life and history of a family.
During the 1960's, Dr. Cicely Saunders, a British physician began the
modern hospice movement by establishing St. Christopher's Hospice near
London. Cicely Saunders is regarded as the founder of the modern hospice
movement. Dr. Saunders founded St. Christopher's in 1967, which charted
new directions in both the philosophy and techniques for treatment of the
terminally ill. When planning St. Christopher's, Dr Saunders stated: «The

72
name hospice, 'a resting place for travelers or pilgrims,' was chosen
because this will be something between a hospital and a home, with the
skills of one and the hospitality, warmth, and the time of the other».
In the late 1960's, several students at Yale University heard about a
program in England that offered special care for people diagnosed with an
irreversible illness. The students invited Dr. Cicely Saunders, founder of
St. Christopher's Hospice in London, to speak at Yale, and were
subsequently inspired to open such a place here in the United States. Her
lecture, given to medical students, nurses, social workers, and chaplains
about the concept of holistic hospice care, included photos of terminally ill
cancer patients and their families, showing the dramatic differences before
and after the symptom control care.  This lecture launched the following
chain of events, which resulted in the development of hospice care as we
know it today. In the United States today, over 3,000 local hospice and
palliative care programs offer specialized care to people suffering from
fatal illnesses, such as cancer. Good hospices are rooted in, and responsive
to, the communities they serve, and to the people who live and die there.
There is well-established hospice and palliative care in Canada, Australia,
New Zealand, and much of Asia and Western Europe. Hospice and
palliative care is now available in over 40 countries worldwide, including
many less-developed nations.
World Health Organization sets standards for palliative care and pain
control, calling it a «priority». But studies show that most patients still
receive little or no effective palliative care, and pain is often very poorly
controlled, primarily due to lack of medical knowledge, to unfounded fears
of addiction, and (in less-developed nations) to shortage of opioids.
Hospice philosophy is a shift from usual medical treatments, in
which health professionals strive to cure disease. Hospice services are not
intended to speed up or prolong the dying process, but focus instead on
relieving pain and other symptoms. Hospice caregivers are concerned with

73
enhancing the quality of remaining life by keeping patient as alert and
comfortable as possible in a familiar environment with family and friends.
Hospice is a special kind of care designed to provide sensitivity and
support for people in the final phase of a terminal illness. Hospice care
seeks to enable patients to carry on an alert, pain-free life and to manage
other symptoms so that their last days may be spent with dignity and
quality at home or in a home-like setting. In accordance with the hospice
philosophy, the rights of the terminally ill are the following:
The right to compassionate and confidential care.
The right to enjoy the greatest possible quality of life.
The right to die with dignity, as he or she perceives dignity.
The right to participate in the management of the remaining life span.
The right to die in familiar surroundings without pain and with loved
ones present.
Hospice services generally include: 1. Basic medical care with a
focus on pain and symptom control. 2. Medical supplies and equipment as
needed. 3. Counseling and social support to help patient and patient`s
family with psychological, emotional, and spiritual issues. 4. Guidance
with the difficult, but normal, issues of life completion and closure. 5. A
break (respite care) for caregivers, family, and others who regularly care
for the patient. 6. Volunteer support such as meal preparation or errand
running.
Hospice care brings compassion, care and support to individuals and
their families transitioning through life-limiting illness while providing
outreach, education and expertise in grief support to the entire community.
Hospice is a concept designed to help persons diagnosed with a serious
illness to live more comfortably and as fully as possible. Hospice care is a
special approach designed to give the same care in the final phase of life
that is given in the first. At a time when nothing more can be done to cure
the disease, there is still so much that can be done for the patient. So,

74
hospice care’s goal is to relieve pain, fear and loneliness.
GENETICS AND ETHICS
I. Specific Features of Ethical Problems in Genetics.
II. Ethical Problems of Genetic Testing.
III. Cloning.

Literature
Annas, George J., and Alias, Sherman. Gene Mapping Using Law and
Ethics as Guides. Oxford University Press, 1992.
Davis Joel. Mapping the Code: The Human Genome Project and the
Choices of Modern Science. John Wiley & Sons, Inc., 1990.
David Suzuki, Peter Knudtson. Genethics: The Clash Between the New
Genetics and Human Values. Harvard, 1995.
Emery A. Psychological Aspects of Genetic Counseling. Academic Press,
Inc., 1985.
John Harris. Ethics and the Genetic Revolution. Oxford University Press,
1998.

Reports, synopses, course and term paper

Perspectives and Challenges of Cloning.
Genetic Discrimination.
Ethical Foundations of Genetic consultations.
Religious views on human cloning.

Genetics is the study of genes and their role in inheritance. Genetics

provides important tools in the investigation of the function of a particular
gene, e.g. analysis of genetic interactions. Within organisms, genetic
information is generally carried in chromosomes, where it is represented in
the chemical structure of particular DNA molecules.
Genetic research raises ethical and moral questions that the public,

75
researchers, and policy-makers must consider. This will demand a major
shift away from the almost exclusively human or homocentric focus which
has been so pervasive in the Western ethics and wider cultural traditions
for almost two thousand years. Aristotle held that since «nature makes
nothing without some end in view, nothing to no purpose, it must be that
nature has made (animals and plants) for the sake of man». This idea that
animals and plants are created for humankind — either by God or the
processes of nature — has dominated our attitudes to animals, plants and
the rest of creation for many centuries.
As Descartes used to say the goal of human knowledge and
technology was to make humans «the masters and creators of nature».
Furthermore such philosophers as Hobbes, Locke and Jeremy Bentham
dismissed the medieval view of the cosmos as organic and substituted.
Instead of it they put forward the mechanistic view of nature and its law.
For these philosophers the best way to understand the cosmos was to see it
as a giant clock. Furthermore these scientists of the Enlightenment viewed
science, and its handmaiden technology, as a tool designed to give humans
the power to dominate and manipulate the earth in whatever way they saw
fit in order to promote human well-being and betterment. Scientists,
working in the field of genetics and biotechnology discovered the insights
and technology which people like Francis Bacon dreamed about. This new
technology gives humans the power to manipulate the building blocks of
life in order to reshape the natural world in the most extraordinary way.
Most of the problems in genetic engineering deal with the question
whether they will be damaging to human health or the environment or not.
What are these problems? The fundamental point is whether genetic
engineering respects the intrinsic rights of other creatures. Having studied
this problem one might then move on to another ethical question
associated with technology — whether the risks to the environment and
human health from genetic engineering are serious enough to warrant a

76
moratorium on deliberate release of genetically modified organisms
nowadays. The push to patent genetically engineered organisms raises the
basic ethical question: Is it proper to patent or claim ownership over living
organisms?
Besides the potential harmful risks that can be envisioned today,
genetic engineering may also pose risks that we do not have sufficient
knowledge about at the moment. It is after all a very young science with
many new discoveries being made in a very short period of time. It is
estimated that the quantity of information in the science of genetics is
doubling every two years.
Unlike most other technologies, genetic engineering does not leave
room for mistakes. Results of harmful risks in this technology cannot be
recalled and fixed, but they may become the negative heritage to countless
future generations.
Biologist George Wald, Nobel Prize winner and Harvard professor,
wrote that recombinant DNA technology [genetic engineering] faces our
society with problems unprecedented not only in the history of science, but
also that of life on the Earth. It gives humans the ability to redesign living
organisms, the products of some three billion years of evolution.... It
presents probably the largest ethical problem that science has ever had to
face. Our morality up to now has been moving forward without learning
everything. Going ahead in this direction may be not only unwise but
dangerous. Potentially, it could cause to life new animal and plant
diseases, new sources of cancer, new epidemics.
Human Genome Project (HGP) is one of the biggest scientific
projects which the aim is to decipher the entire genetic code of human
beings, and to try to understand the functioning of the 40,000 or so genes
that make up the DNA lying at the core of every cell in our bodies.
Thousands of researchers in many countries are engaged in this project.
Although genetic engineering may lead to new cures for inherited diseases,

77
many people express the view that DNA is sacred and that scientists are
hubristically attempting to claim the role of God when they «play» with
DNA.
Genetic testing is a kind of medical test that identifies changes in
chromosomes, genes or proteins. It is mainly used to find changes that are
associated with inherited disorders. The results of a genetic test can
confirm or rule out a suspected genetic condition or help to determine the
chance of a person to develop or get rid of a genetic disorder. Testing has
both pros and cons. The decision to be tested or not is personal.
Presymptomatic and diagnostic testing raises issues of counseling,
confidentiality and justice. Such testing may allow clinicians to predict
diseases or clarify susceptibility at a time when medicine may not have
the ability to prevent or cure the conditions that are identified. Both the
public and health care professionals often have a limited grasp of the
distinction between prediction and susceptibility or risk. Genetic testing
presents unique problems by identifying risk for diseases that has special
meaning for patients and for family members who may not be under the
care of the clinician providing the test.
Clinicians should discuss with patients the degree to which a
particular genetic risk factor correlates with the likelihood of developing
disease. Testing should not be undertaken until these issues are fully
explored with the patients and the potential consequences of the test are
clear to them. They should also realize the impact of the test on their well-
being. They must understand how the results of the test will influence their
family members and how insurers and social institutions might use them.
As more information about the genetic risk for certain diseases becomes
available, physicians must be aware of the need for confidentiality
concerning the results of genetic tests. Many federal governments regulate
the access of employers and insurers to such information. Additional
ethical problems exist, such as: who of the family members should be

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informed of the results of genetic tests. Physicians should be sensitive to
these ethical problems, and testing should not be undertaken until all
problems are fully discussed and their consequences are well understood.
The potential for stigmatization and insurance and job discrimination
require that physicians ensure the confidentiality of data. However, the
presence of a genetic risk factor or genetic disease in a family member
raises the possibility that other blood relatives are at risk. The physician
should seek the affected patient’s consent in encouraging potentially
affected family members to seek genetic counseling if it may affect
treatment or major life decisions.
Cloning an organism means to create a new organism with the same
genetic information as an existing one. Recently the prospect of human
cloning has been the subject of considerable public attention and sharp
moral debate around the world. Many people have serious concerns about
the cloning. They think this kind of research raises important ethical
problems. Some of them are:
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 make up is selected in advance. They
might come to be considered more like products of a designed
manufacturing process than «gift» 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,

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or by preserving and perpetuating outstanding genetic traits, including the
possibility, someday in the future, or 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»;
mother 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.
However, the success rate has been very low, for example, a sheep
Dolly was born after 276 failed attempts. Cloning opens up an even greater
opportunity than some reproductive technologies do for manipulations
with the genetic component of the personality and contributes to its further
devaluation. Many teologists hold that man has no right to claim the role
of the creator of his likes or to choose their genetic prototypes, thus
determining their personal characteristics at his discretion. The conception
of cloning is a definite challenge to the very nature of the human being and
to the image of God inherent in him. The integral parts of which are the
freedom and uniqueness of the personality. The «printing» of people with
specified parameters can appear welcome only to adherents of totalitarian
ideologies.

THE PRINCIPLES OF ETHICS IN PSYCHIATRY

80
 I. Bioethical Approach to Psychiatry.
II. The Ethical and Professional Basis of the Physician-patient
Relationship.
III. Central Ethical and Professional Practices in Psychiatric Care.
IV. Involuntary Psychiatric Treatment.

Literature
American Psychiatric Association: The Principles of Medical Ethics With
Annotations Applicable to Psychiatry. Washington: APA, 2001.
Brody H. The Healers' Power. New Haven and London: Yale University
Press, 1992.
Dyer AR. Ethics and Psychiatry: Toward Professional Definition.
Washington, D.C.: American Psychiatric Press Inc., 1988
Green S., Sidney Bloch S. An Anthology of Psychiatric Ethics, 2006.
Kleinman A. The Illness Narratives: Suffering, Healing, and the Human
Condition. New York: Basic Books; 1988.
Rescher, Nicholas. Fairness: Theory & Practice of Distributive Justice.
New Brunswick, NJ: Transaction, 2002.
Viafora, Corrado, ed. Clinical Bioethics: a Search for the Foundations.
Dordrecht/ Boston: Springer, 2005.

Reports, synopses, course and term paper

Rational Decision-making and Mental Incompetence.
Real or Perceived Coercion.
Psychiatric Issues in End-of-life Care.
Evolution of Ethical Standards in Psychiatry.

Medicine is a healing art and a science both. The dynamics of this

combination are best reflected in psychiatry, the branch of medicine that
specializes in mental disorders. First of all, arising of the bioethical

81
problems in psychiatry was result of the development of medicine:
expanding frontier of knowledge on brain functioning, the expansion of
psychotherapeutic approaches, and the advent of psychotropic medication
for mental disorders. Another reason was awareness of sociocultural
factors to understand illness and help-seeking behaviors. The third reason
was political abuse of psychiatry, for instance the most famous scandal
with MK-ULTRA project. It was the code name for a covert CIA mind-
control and chemical interrogation research program, run by the Office of
Scientific Intelligence, that began in the early 1950s and continued at least
through the late 1960s. There is much published evidence that the project
involved the surreptitious use of many types of drugs, as well as other
methodology, to manipulate individual mental states and to alter brain
function.
It is evident that phenomena such as the increasing migratory flows
and the globalization of prevailing social criteria referred to the economy,
trade, religion and the perception and the attribution of the causes of
disease have determined a shift in the world cultural balance that have
direct repercussions on World Mental Health. Being a branch of medicine,
psychiatry has many special features. The realizing and implementation of
ethical guidelines in psychiatry require attention to cultural sensitivity
more than in surgery or therapy. For example, in Eastern cultures, social
integration is emphasized more than autonomy; affiliation is more
important than achievement. In some traditional cultures the collectivity of
the community is valued rather than the individuality of its members.
Decisions are made not at an individual level but on a familial, tribal or
communal level, in the best perceived collective interest. That’s why
psychiatry has special aims: exploration of the similarities and differences
in the manifestations of mental illness in different cultures; identification
of cultural factors that predispose to mental illness and mental health;
assessment of the effect of identified cultural factors on the frequency and

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nature of mental illness; study of the form of treatment practised or
preferred in different cultural settings; comparison of different attitudes
toward the mentally ill in different cultures.
Psychiatry is more value-laden than any other branch of medicine
essentially because it is concerned with areas of human experience and
behavior in which human values are particularly diverse.
General ethical guidelines were formulated by World Psychiatric
Association (WPA) as an international umbrella organization of
psychiatric societies. WPA General Assemblies have consistently
formulated ethical guidelines on psychiatric practice, including the Hawaii
Declaration of 1977, its amendment in Vienna in 1983, and, more recently,
the Madrid Declaration of 1996, expanded in 1999. Another international
act is the document of UN «The protection of persons with mental illness
and the improvement of mental health care».
Actually, psychiatrists share the same ethical ideals as all physicians
and are committed to compassion, fidelity, beneficence, trustworthiness,
fairness, integrity, scientific and clinical excellence, social responsibility,
and respect for persons. Psychiatrists endeavor to embody these principles
in their diverse roles as diagnosticians, treating physicians, therapists,
teachers, scientists, consultants, and colleagues. However, psychiatry has
the specific feature, which differs it from any other brunch of medicine.
Mental illnesses directly affect thoughts, feelings, intentions, behaviors,
and relationships – those attributes that help define people as individuals
and as persons.
Since M. Foucault’s books which argued that madness was silenced
by Reason, losing its power to signify the limits of social order and to
point to the truth, madness became a kind of metaphysical enemy of
modern society. Foucault also argues that madness during the Renaissance
had the power to signify the limits of social order.
Reaction to abuse of psychiatry was so-called anti-psychiatrical

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movement. The origins of what is called anti-psychiatry stem from
concerns that arose due to the misuse of psychiatric ideas to engage in
social control. The Soviets invented a diagnosis for persons who oppose
the will of the state, as an excuse for hospitalizing them. In the 1930s
several controversial medical practices were introduced including inducing
seizures (by electroshock, insulin or other drugs) or cutting parts of the
brain apart (leucotomy or lobotomy). Both came into widespread use by
psychiatry, but there were grave concerns and much opposition on grounds
of morality, harmful effects, or misuse. In the 1950s new psychiatric
drugs, notably the antipsychotic chlorpromazine, were designed in
laboratories and slowly came into preferred use. One of the founders of
anti-psychiatry Thomas Szasz argues that «mental illness» is an inherently
incoherent combination of a medical and a psychological concept, but
popular because it legitimizes the use of psychiatric force to control and
limit deviance from societal norms. Michel Foucault, Erving Goffman,
Deleuze and Guatarri, and others criticized the power and role of
psychiatry in society, including the use of "total institutions," "labeling"
and stigmatizing. The novel One Flew Over the Cuckoo's Nest became a
bestseller, resonating with public concern about involuntary medication,
lobotomy and electroshock procedures used to control patients.
Observation of the abuses of psychiatry in the Soviet Union in the so-
called Psikhushka hospitals also led to questioning the validity of the
practice of psychiatry in the West. In particular, the diagnosis of many
political dissidents with schizophrenia led some to question the general
diagnosis and punitive usage of the label schizophrenia. This raised
questions as to whether the schizophrenia label and resulting involuntary
psychiatric treatment could not have been similarly used in the West to
subdue rebellious young people during family conflicts.
Anti-psychiatry came to challenge a «biomedical» focus of
psychiatry (defined to mean genetics, neurochemicals and pharmaceutics

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drugs). There was also opposition to the increasing links between
psychiatry and pharmaceutical companies, which were becoming more
powerful and were increasingly claimed to have excessive, unjustified and
underhand influence on psychiatric research and practice.
The pharmaceutical industry is one of the most profitable and
powerful in existence, there are many financial and professional links
between psychiatry, regulators, and pharmaceutical companies. The
number of psychiatric drug prescriptions has been increasing at an
extremely high rate since the 1950s and show no sign of abating. In the
United States antidepressants and tranquilizers are now the top selling
class of prescription drugs, and neuroleptics and other psychiatric drugs
also rank near the top, all with expanding sales.
The therapeutic alliance between psychiatrists and patients struggling
with mental illness thus has a special ethical nature. Moreover, because of
their unique clinical expertise psychiatrists are entrusted with a heightened
professional obligation: to prevent patients from causing harm to
themselves or others. Psychiatrists may consequently be required to treat
patients against their wishes and breach the usual expectations of
confidentiality. Psychiatrists may also be called upon to assume duties of
importance to society, such as legal or organizational consultation, that are
beyond the scope of usual clinical activities. These features of psychiatric
practice may therefore create greater asymmetry in interpersonal power
than in other professional relationships and introduce ethical issues of
broad social relevance. For all these reasons, psychiatrists are called upon
to be especially attentive to the ethical aspects of their work and to act with
great professionalism.
Psychiatrists are entrusted to serve in a special role in the lives of ill
persons and in society as a whole. Psychiatrists’ ability to serve in this
special role is predicated on the fulfillment of the ethical principles that
ground the field.

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 Respecting patients’ confidentiality is especially important for
psychiatrists because patients entrust them with highly personal and often
sensitive information. Patients’ willingness to make painful, stigmatizing,
or embarrassing disclosures depends on their trust in the physician-patient
relationship and its expectation of confidentiality. Beyond this therapeutic
rationale, there are ethical duties that arise from principles of beneficence
and nonmaleficence.
Stigma creates a vicious cycle of discrimination and social exclusion
for those who suffer from a mental disorder and all of those who are
associated with them. Stigma is the single most important barrier to quality
of life of mental health consumers and family members—more so than the
illness itself—and a major impediment to mental health reform and
development. As the majority of people with a mental illness are now
treated in community settings, negative public opinions can have potent
consequences for them and their families. Consequences of stigma such as
unemployment, lack of housing, diminished self-esteem, and weak social
support can be major obstacles to recovery, influence long term prognosis,
and promote disability. Stigma and the expectation of stigma can also
produce serious disruptions in family relationships and reduce normal
social interactions because of a desire for secrecy.
The exchange of patient information with families and others should
occur with the patient’s explicit informed consent and when it is consistent
with the psychiatrist’s best clinical judgment. The psychiatrist’s goal when
involving families in a patient’s treatment is to facilitate the coordination
of care, the gathering of data, and the management of expectations.
Although family members may have been excluded from treatment
discussions in the past, evolved conceptualizations of patient autonomy
now recognize the importance of the patient’s relationships more fully.
Thus, the absolute — even routine — exclusion of families and significant
others may not be ethically or clinically justified.

86
 Explicit permission is important for the ethical disclosure of patient
information by psychiatrists to family members, teachers, or others.
However, psychiatrists may accept or receive information under many
circumstances. Psychiatrists should be sensitive to the feelings this kind of
information disclosure may raise for patients and maintain communication
with them when it occurs.
Several important considerations guide the confidentiality of medical
information:
1. Patients should be told of the limits to confidentiality at the beginning of
the physician-patient relationship and as events arise that create potential
revelations.
2. Disclosure of confidential information should occur only if informed
consent has been given by the patient or if it is necessary to protect the
patient or third parties from imminent harm, in a manner consistent with
relevant legal statutes.
3. Disclosure of patient information should always be limited to the
requirements of the situation. This limitation is particularly relevant when
state privacy rules provide a lower standard of protection.
4. In their progress notes, psychiatrists should record only the information
necessary for continued patient care.
5. Psychotherapy notes may afford further, although not absolute,
protection of patient information when kept separate from other
components of the medical record. Psychotherapy process comments,
therapist formulations and hypotheses, details of patient’s dreams and
wishes, and intimate personal details of patients or related individuals
should be recorded in these psychotherapy notes rather than the medical
record.
In psychiatric practice, as in other areas of medicine, however, the
patient may seek care because of distress from significant mental and
physical symptoms. This need for clinical care, especially in cases of

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severe illness, creates an asymmetry or disparity in the relationship:
patients are relatively less empowered than physicians. This disparity
creates a special ethical obligation for physicians who must place the
unique needs of the patient above their own professional or personal
interests. Physicians, furthermore, must be vigilant for situations that can
reasonably be expected to cause physical, sexual, psychological, or
financial harm to the patient. For psychiatrists, ethical obligations to the
patient arise from a special sensitivity to the trust and dependence created,
in part, by the communication of highly personal information.
At times, the nature and specific obligations of the physician-patient
relationship can vary because of a patient’s age or cognitive capacity. For
instance, when a seriously ill patient’s cognitive capacity is compromised,
the process of informed consent may include the next of kin or a legally
recognized substitute decision-maker.
Third party obligations and the clinical context may also influence
the ethical expectations of the physician-patient relationship. For instance,
a psychiatrist providing psychoanalytic treatment to a long-term patient
should not, under ordinary circumstances, disclose key aspects of the
treatment to anyone else. On the other hand, a psychiatrist who serves as a
consultant in providing a psychosomatic medicine evaluation undertakes
different clinical duties, will have different responsibilities in the patient’s
care, and may have different ethical obligations in comparison with the
long-time psychotherapist. The consulting physician retains the
fundamental responsibility to serve the well-being and interests of the
patient, but will naturally share clinical information, diagnostic
impression, and treatment plan recommendations with appropriate clinical
staff members. Similarly, in forensic, employment, or military settings, the
physician’s obligation to preserve a patient’s confidentiality may be
limited or redefined because of obligations to a third party.
Because of the complex variations in physician-patient relationships,

88
the reasonably anticipated duties and limits of these different relationships
should, when possible, be discussed with the patient. For example, in
treating an adolescent in psychotherapy, it will be important to talk with
him or her about the kinds of issues that can be «kept private» in their
discussions, and which kinds of issues require informing others (e.g.,
parents, state officials, referral physicians, clinical staff, etc). In a health
care system where patients are transferred from one physician to another,
the patient should receive appropriate clinical information, such as the
reasons for subsequent treatment, the consequences of foregoing treatment
and the reasons for transitioning the patient’s care to another clinician.
Because of their special expertise, psychiatrists sometimes use their
training to serve specific social institutions (e.g., employers, the judicial
system, the military). Under a variety of circumstances, a psychiatrist may
have competing duties to an institution and an individual patient, for
instance, or to two patients or two institutions.
When dual or overlapping roles cannot be minimized (e.g., clinical
research situations, employee health centers, correctional settings, school-
based mental health programs) it is especially important to inform the
patient about the role issues and conflicting ethical obligations. Informed
consent «cautions» or «warnings» about overlapping roles should be
commonplace in these settings. Attention should be paid to subtle changes
in the patient's view of the relationship; cautions and reminders should be
repeated if potentially harmful self-disclosures are anticipated. Language
must be clear on any limitations of the professional opinion, using terms
and phrasing that describe the appropriate level of uncertainty. Through
such efforts, institutions and patients — or individuals undergoing
evaluations — are reminded that the psychiatrist fulfills two roles, and that
disclosures may be used in ways that are not therapeutic.
There is one role that, despite its basis in medical knowledge, is
absolutely prohibited in all fields of medicine. Physicians may not

89
ethically participate in any manner that supports, facilitates, or enacts
human torture or the development and monitoring of interrogation
techniques that involve torture.
Honesty and trust are elemental values of a profession and
fundamental expectations for the patient seeking psychiatric care.
Discussions and interactions in psychiatric practice often deal with highly
sensitive and personal information. Psychiatrists may be occasionally
tempted to skirt or «soften» the truth in order to avoid harm to a patient. In
general, omission (intentional failure to disclose) and evasion (avoidance
of telling the truth) will undermine a trusting and constructive relationship
between physician and patient and is not appropriate. In addition, releasing
inaccurate or misleading clinical information to insurers or employers is a
specific example of dishonesty and may constitute fraud. Such behavior
undermines trust in the profession as a whole and in third-party
interactions in particular. At the same time, out of respect for patient
privacy, the ethical physician should reveal only the minimum information
necessary for third party review.
Protecting patients from harmful disclosures, as in very acute
situations, in therapy with fragile or minor patients, or in end-of-life
decision-making — when deemed essential — must occur with the
strictest concern for patient values and autonomy. This protective measure
should be temporary, and ideally will occur with prior discussions with
appropriate persons who are in accord with such an approach. Psychiatrists
communicate with numerous agencies and individuals during patient
treatment. They are responsible for the usual physician contact with
funding and reimbursement agencies, families, employers, and other third
parties. However, because of their expertise in human behavior,
psychiatrists are often asked, formally and informally, for information
justifying or excusing patient actions. This offers numerous opportunities
for ethical missteps.

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 Ideally, principles of trustworthiness and integrity will over-ride
inappropriate attempts to benefit an individual patient or psychiatrist.
Deceptive conduct of any kind cannot be generalized as a model for
others, and, when it becomes known, undermines patient trust in the
profession as a whole.
Specific examples of fraud in psychiatric practice include making
false or intentionally misleading statements to patients, falsifying medical
records, research, or reports, submitting false bills or claims for service,
lying about credentials or qualifications, supporting inappropriate
exemptions from work or school, practicing outside one’s area of
professional competence or beyond one’s authorized scope, providing
unnecessary treatment, and taking credit for another’s work. Further
illustrations of overt (and legally actionable) dishonesty include writing a
prescription for a patient in a family member’s name, or writing
prescriptions for a larger number of pills than necessary in order to reduce
insurance co-payments. These actions are not ethically acceptable in the
practice of psychiatry.
The field of psychiatry as a whole is attentive to the use of language
and the interpersonal aspects of obtaining informed consent. The manner
in which information is presented, the choice of facts that are included or
omitted, and the selection of alternatives that are offered have distinct
effects on patient choices. Distorting influences on the consent process
may consequently arise from the simplest patient interactions. These
include telephone conversations, cross-coverage, and curbside encounters
in the clinical setting. Even language used in informal interactions with
patients can carry the weight of professional opinion and is colored by the
vulnerabilities of knowledge and power inherent to the patient role. When
seeking consent, psychiatrists thus must be careful not to influence the
patient unduly.
Adults are presumed capable of making their own decisions, with the

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clinical and legal burden of proof falling on those who wish to prove
otherwise. Assessments of decision-making capacity should follow clinical
models of assessment and the legal standards of the jurisdiction.
Physicians maintain the highest standards of informed consent when
they become familiar with, and endeavor to honor, the specific authentic
and enduring personal values of their individual patients. The requirement
of voluntariness in informed consent thus affirms the autonomous and
values-shaped decision making of the individual and it prohibits coercive
pressures in the consent process. In the practice of psychiatry, these issues
may be particularly salient because some symptoms of certain mental
illnesses can prevent an individual from discerning, expressing, and
enacting his or her specific authentic and enduring personal values in some
circumstances. Furthermore, the experience of dependence, societal
marginalization, and insufficient access to clinical care may create a
situation of desperation that may interfere with voluntary decision making.
It is important to note that these vulnerabilities need not confer incapacity.
Nonetheless, they should be explored in order to optimize a patient’s
decision-making. This is particularly important in psychiatry where, even
if patients are decisionally capable, both internal and external factors (e.g.,
the patient’s illness, stigma, lack of resources) can make them vulnerable
to coercive influences.
Important exceptions to informed consent exist:
1. Genuine emergencies do not require informed consent. Emergency care
occurs in the framework of implied or presumed consent. That is, in
emergency situations in which reasonable persons would want the
intervention it is ethical to proceed as if consent exists.
2. Care for children or incompetent patients requires consent from parents
or legally recognized surrogates. Assent of incompetent individuals (i.e.,
acquiescence as opposed to informed consent) is obtained whenever
possible.

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3. Patients may also waive their right to informed consent. This exception,
however, presumes competence to do so.
4. Finally, the doctrine of therapeutic privilege allows a physician to
withhold information if it is truly damaging to the patient. But such an
exception should be rare. Withholding information about side effects, for
example, in the hope of increasing compliance is not acceptable.
Because the concepts of autonomy and informed consent have a legal
basis, they may cast the clinical situation in an adversarial light. This view
is antithetical to ethical practice. Although the ultimate choice to consent is
made by an individual patient, autonomous choice does not take place in a
vacuum; it must be nurtured by continued dialogue. Ultimately, the ideal
understanding of informed consent is clinical, an important reminder of
respect for the strengths of patients and the need for transparent,
collaborative, and enduring alliances. Psychiatrists who strive to develop
these relationships with their patients will easily exceed the requirements
of ethics and law.
Common assessment standards expressed in ethics and law include
evidencing a choice, understanding relevant information, manipulating
information rationally, and appreciating the situation and its consequences.
Elements of each standard are often necessary to a competent decision and
apply to the specific task at hand.
Psychiatrists in particular have special preparation with respect to the
mental status examination and certain cognitive evaluation procedures.
Rather than screen all individuals, psychiatrists may use capacity
assessments in a targeted fashion when patient decisions or discussions
raise concerns. Psychiatrists may be asked to perform capacity assessments
when patients or research participants exhibit cognitive deficits, appear to
lose decision-making capacity, or manifest atypical behaviors and
decisions. Although any physician may conduct the assessment,
psychiatrists are specially trained to identify the vulnerabilities of persons

93
with mental retardation, delirium, or hopeless outlook as well as to identify
cognitive strengths of even severely ill persons. Psychiatrists recognize
that deficits in decision-making capacity may be overcome by targeted
educational and clinical interventions. These often include part-by-part and
repeated information disclosures, or use of a single trusted clinician to
communicate information. Interventions to reduce anxiety, diminish
psychotic symptoms, or reduce sedating side effects are equally valuable
in overcoming incapacity. Other interventions may include videotape,
written, or group education sessions.
Psychiatrists may apply assessment standards on a «sliding scale»,
with more stringent assessments and higher thresholds of capacity required
for decisions that are more consequential, complex, or risky. When
incapacity persists surrogate decision makers may be invoked in
accordance with local law. Surrogate decision-makers themselves should
also be held to appropriate standards of decision-making capacity.
Capacity assessment is particularly relevant for determining the
wishes of patients who want treatment or research procedures after they
become incapacitated. In such circumstances capacity assessment tools or
independent interviewers may be helpful in maintaining standards of
surrogate decision-making and adherence to patient wishes. Reminding
patients of their earlier preferences can also serve to enhance their
decision-making. These techniques, however, do not, overcome the
clinician or investigator’s primary obligation to provide appropriate
information and assessment.
For psychiatrists, mandated treatment creates inherent ethical
tensions. It requires great sensitivity to principles of respect for persons
and social responsibility because psychiatrists are contributing to decisions
directly controlling patient choices. This kind of power — in which a
patient’s personal freedoms are limited and treatment decisions are being
made — is generally exercised by careful balancing of principles that

94
value both the individual and the community.
Many countries have mental health laws governing involuntary
commitment. Mental health law is the area of the law that is applied
specifically to persons with a diagnosis of mental illness, and to the people
involved in managing or treating others in this situation. An example is the
Mental Health Act 1983 in England and Wales. These acts codify aspects
of the treatment of mental illness and provides rules and procedures to be
followed and penalties for breaches. Mental health acts are largely used in
the management of psychosis where a person has lost the ability to test
reality. They may also be used for other conditions including personality
disorders. The laws generally allow for compulsory treatment in a
psychiatric hospital or in the community.
Involuntary hospitalization is usually justified by patients’ imminent
dangerousness to themselves or others, or their inability to meet basic
needs. To meet these criteria, dangerousness must be likely in the near
future, and related to a major mental illness. In acknowledgement of the
seriousness of depriving a patient of freedom, involuntary commitment
usually requires judicial review, access to legal counsel, and consideration
of the least restrictive alternative to hospitalization.
Separate authorization is often required for treatment with psychiatric
medications. In collaboration with the patient (and/or surrogate decision-
makers) ethical psychiatrists discuss those treatments that are most likely
to restore the patient’s freedom – if necessary, in incremental fashion. This
requires sensitivity to the coercive nature of commitment, the informed
consent process, and the patient’s decision-making capacity. When there is
a treatment refusal, and efforts to engage in collaborative decision-making
have been insufficient to prevent harm, administrative or legal appeals
may be available to review treatment and may require a showing of
impaired capacity.
Another common form of involuntary care is mandatory outpatient

95
treatment. Although many states retain the same criteria for outpatient
commitment as inpatient commitment, the focus is increasingly on
repeated deteriorations that require hospitalization. The likelihood of
continued deterioration without intervention, a treatment plan that holds
the prospect of stabilization and involvement of the community treatment
team are important ethical requirements.
Outpatient commitment should be informed by concern for patient values,
past clinical history, and decision-making capacity. Specific procedures
that address non-adherence to recommended treatment should be clear to
patients and clinicians, from mandated emergency evaluations to court
hearings.
Expectations for taking psychotropic medications should be clearly
stated in a formal treatment plan. Forced medication, however, remains a
matter of some legal controversy. The ethical problem, as in inpatient
settings, remains one of creating a class of persons for whom psychiatrists
are required to care, yet who they are unable to treat.
Ethical obligations to patients committed in the community may
require psychiatrists to advocate for greater resources, community-based
services, and parity with other forms of medical care. Active outreach and
intensive service coordination are among the means for meeting these
obligations and ending the suffering of people living with mental illness
who may not receive adequate care without such intensive efforts.
Psychiatric commitment of children by parents or guardians requires
even greater attention to the effects of confinement and loss of liberty. In
such cases psychiatrists endeavor to assure a balance between the fewest
obstacles to treatment and the greatest protections from unnecessary
institutionalization. The ethical ideal is one of the child’s best interest,
appropriate high quality care, and psychiatric participation.
Physical restraint or involuntary seclusion of a patient shall not be
employed except in accordance with the officially approved procedures of

96
the mental health facility and only when it is the only means available to
prevent immediate or imminent harm to the patient or others. It shall not
be prolonged beyond the period which is strictly necessary for this
purpose. A patient who is restrained or secluded shall be kept under
humane conditions and be under the care and close and regular supervision
of qualified members of the staff. Every patient not admitted involuntarily
shall have the right to leave the mental health facility at any time.
The document of UN «The protection of persons with mental illness
and the improvement of mental health care» describes possible cases of
involuntary admission:
a) there is a serious likelihood of immediate or imminent harm to that
person or to other persons;
b) in the case of a person whose mental illness is severe and whose
judgment is impaired, failure to admit or retain that person is likely to lead
to a serious deterioration in his or her condition or will prevent the giving
of appropriate treatment that can only be given by admission to a mental
health facility in accordance with the principle of the least restrictive
alternative.
Involuntary admission or retention shall initially be for a short period
as specified by domestic law for observation and preliminary treatment
pending review of the admission or retention by the review body. A mental
health facility may receive involuntarily admitted patients only if the
facility has been designated to do so by a competent authority prescribed
by domestic law.

AIDS: MORAL AND SOCIAL ASPECTS

I. The AIDS Pandemic.
II. The Problem of AIDS/HIV Origin. Principal Ways of Transmission.
III. Social and Psychological Consequences of the AIDS Pandemic.
AIDS Stigma.

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IV. AIDS - infected People and Medical Ethics.
V. Legal Issues of AIDS.

Literature
AIDS: An Epidemic of Ethical Puzzles. Hastings Center. Brookfield, VT:
Dartmouth, 1991.
Duesberg, Peter H. Inventing the AIDS virus. Washington: D.C., Regnery
Publishing, 1996.
Gray, Joni N., Lyons, Phillip M., and Melton, Gary B. Ethical and Legal
Issues in AIDS Research. Baltimore, MD: Johns Hopkins University Press,
1994.
Shilts R. And the Band Played On: Politics, People, and the AIDS
Epidemic. New York: St. Martin's Press, 1987.

Reports, synopses, course and term paper

AIDS as a social phenomenon.
Religious aspects of AIDS.
AIDS: The history of investigation.
The principle of justice in medical practice.
The demography of AIDS.

Reports, synopses, course and term paper

AIDS as a social phenomenon.
Religious aspects of AIDS.
AIDS: The history of investigation.
The principle of justice in medical practice.
The demography of AIDS.

Acquired Immune Deficiency Syndrome, or simply AIDS, is a

deadly disease that is spreading through the human population at an

98
alarming rate. It is a global catastrophe of immense social and economic
proportions. Today it is the fourth leading cause of death in the world.
Globally, between 33.4 and 46 million people currently live with HIV. In
2005, between 3.4 and 6.2 million people were newly infected and
between 2.4 and 3.3 million people with AIDS died, an increase from 2003
and the highest number since 1981. As of January 2006, the Joint United
Nations Programmed on HIV/AIDS and the World Health Organization
estimate that AIDS has killed more than 25 million people, making it one
of the most destructive epidemics in recorded history.
The AIDS epidemic was discovered on June 5, 1981, when the U.S.
Centers for Disease Control and Prevention (CDC) reported a cluster of
Pneumocystis carinii pneumonia in five homosexual men in Los Angeles.
CDC originally classified AIDS as GRID which stood for Gay Related
Immune Disease. However, after determining that AIDS is not isolated to
homosexual people the name was changed to the neutral AIDS. In 1982,
the CDC introduced this term to describe the newly recognized syndrome.
Acquired Immune Deficiency Syndrome is a collection of
symptoms and infections in humans resulting from the specific damage to
the immune system caused by the human immunodeficiency virus (HIV).
Two primary strains of human immunodeficiency viruses have been
identified: HIV-1 and HIV-2. HIV-1 is more virulent and more easily
transmitted. HIV-1 is the source of the majority of HIV infections
throughout the world, while HIV-2 is not as
easily transmitted and is largely confined to West Africa. The HIV-1 strain
is prevalent in the United States, Europe, and most of Africa; the second
strain, HIV-2, is prevalent mainly in western Africa and more rarely
elsewhere. Some individuals, particularly in Africa, carry both HIV
strains. Both HIV-1 and HIV-2 are of primate origin. The origin of HIV-1
is the Central Common Chimpanzee found in southern Cameroon. It is
established that HIV-2 originated from the Sooty Mangabey, an Old World

99
monkey of Guinea Bissau, Gabon and Cameroon.
Once a person is infected, the incubation period is long – an average
of 8 years (though shorter for those under 5 or over 60 years old) – before
symptoms appear. During this period the virus is concentrated in the
tissues of the lymphatic system. Most people who have recently been
infected by HIV look and feel perfectly healthy. After a few years,
however, many will develop a condition known as AIDS-related complex
(ARC). Its symptoms are intermittent or persistent fever, fatigue,
weakness, diarrhea, malaise, weight loss and abnormally low numbers of
lymphocytic helper T cells in the blood. The symptoms of AIDS are
primarily the result of conditions that do not normally develop in
individuals with healthy immune systems. Most of these conditions are
infections caused by bacteria, viruses, fungi and parasites that are normally
controlled by the elements of the immune system that HIV damages.
Opportunistic infections are common in people with AIDS. HIV affects
nearly every organ system. People with AIDS also have an increased risk
of developing various cancers such as Kaposi sarcoma, cervical cancer and
cancers of the immune system known as lymphomas.
Three of the earliest known instances of HIV infection are as
follows: 1). A plasma sample taken in 1959 from an adult male living in
what is now the Democratic Republic of Congo; 2). HIV found in tissue
samples from a 15 year old African-American teenager who died in St.
Louis in 1969; 3). HIV found in tissue samples from a Norwegian sailor
who died around 1976.
Most researchers believe that HIV originated in sub-Saharan Africa
during the twentieth century. In 1992 U.S. journalist Tom Curtis put
forward what is now known as the OPV AIDS hypothesis, which suggests
that AIDS was inadvertently caused in the late 1950s in the Belgian Congo
by Hilary Koprowski's research into a
polio vaccine. This idea was supported by another journalist, Edward

100
Hooper, who alleged that an experimental oral polio vaccine prepared
using chimpanzee kidney tissue was the route through which simian
immunodeficiency virus (SIV) crossed into humans to become HIV, thus
starting the human AIDS pandemic. Subsequently, this hypothesis has
been refuted by examination of these original polio vaccine stocks and
establishing that they do not contain material of chimpanzee origin.
A minority of scientists have doubts about the connection between
HIV and AIDS, or the existence of HIV, or the validity of current testing
methods. These claims are met with resistance by, and often evoke
frustration and hostility from most of the scientific community, who
accuse the dissenters of ignoring evidence in favor of HIV's role in AIDS,
and irresponsibly posing a dangerous threat to public health by their
continued activities. Some assert that the current mainstream approach to
AIDS, based on HIV causation, has resulted in inaccurate diagnoses,
psychological terror, toxic treatments, and a squandering of public funds.
The debate and controversy regarding this issue from the early 1980s
to the present has provoked heated emotions and passions from both sides.
Although a variety of theories exist explaining the transfer of HIV to
humans, there is no widely accepted scientific consensus of any single
hypothesis and the topic remains controversial.
Medical researches established the three main transmission routes of
HIV: sexual contact, exposure to infected body fluids or tissues and from
mother to fetus or child during prenatal period. It is possible to find HIV in
the saliva, tears and urine of infected individuals, but due to the low
concentration of virus in these biological liquids, the risk is negligible.
The majority of HIV infections are acquired through unprotected
sexual relations between partners, one of whom has HIV. With consistent
and correct use of condoms, there is a very low risk of HIV infection.
Studies on couples where one partner is infected show that with consistent
condom use, HIV infection rates for the uninfected partner are below 1 %

101
per year. Promoting condom use, however, has often proved controversial
and difficult. Many religious groups, most noticeably the Catholic Church,
have opposed the use of condoms on religious grounds, and have
sometimes seen condom promotion as an affront to the promotion of
marriage, monogamy and sexual morality. This attitude is found among
some health care providers and policy makers in sub-Saharan African
nations, where HIV and AIDS prevalence is extremely high. They also
believe that the distribution and promotion of condoms is tantamount to
promoting sex amongst the youth and sending the wrong message to
uninfected individuals. However, no evidence has been produced that
promotion of condom use increases sexual promiscuity. Pope Benedict
XVI commissioned a report on whether it might be acceptable for
Catholics to use condoms to protect life inside a marriage when one
partner is infected with HIV, or is sick with AIDS. Defenders of the
Catholic Church's role in AIDS state that, while they may be against the
use of contraception, they are strong advocates of abstinence outside
marriage. Conversely, some religious groups have argued that preventing
HIV infection is a moral task in itself and that condoms are therefore
acceptable or even praiseworthy from a religious point of view.
This transmission route is particularly relevant to intravenous drug
users, hemophiliacs and recipients of blood transfusions and blood
products. Sharing and reusing syringes contaminated with HIV-infected
blood represents a major risk for infection with not only HIV, but also
hepatitis B and hepatitis C. Needle sharing is the cause of one third of all
new HIV-infections and 50% of hepatitis C infections in Northern
America, China, and Eastern Europe. The risk of being infected with HIV
from a single prick with a needle that has been used on an HIV infected
person is thought to be about 1 in 150. Post-exposure prophylaxis with
anti-HIV drugs can further reduce that small risk. Health care workers
(nurses, laboratory workers, doctors, etc) are also concerned, although

102
more rarely. This route can affect people who give and receive tattoos and
piercing. Universal precautions are frequently not followed in both sub-
Saharan Africa and much of Asia because of both a shortage of supplies
and inadequate training. Moreover, the United Nations General Assembly,
supported by universal medical opinion on the matter, has urged the
nations of the world to implement universal precautions for preventing
HIV transmission in health care settings. The risk of transmitting HIV to
blood transfusion recipients is extremely low in developed countries where
improved donor selection and HIV screening is performed. However, the
overwhelming majority of the world's population does not have access to
safe blood and between 5% and 10% of HIV infections worldwide are
transmitted through the transfusion of infected blood and blood products.
The transmission of the virus from the mother to the child can occur
in uterus during the last weeks of pregnancy and at childbirth. In the
absence of treatment, the transmission rate between the mother to the child
during pregnancy, labor and delivery is 25%. However, when the mother
has access to antiretro viral therapy and gives birth by caesarean section,
the rate of transmission is just 1%. A number of factors influence the risk
of infection, particularly the viral load of the mother at birth (the higher the
load, the higher the risk). Breastfeeding increases the risk of transmission
by 10-15%. This risk depends on clinical factors and may vary according
to the pattern and duration of breast-feeding.
Prevention strategies are well known in developed countries,
however, recent epidemiological and behavioral studies in Europe and
North America have suggested that a substantial minority of young people
continue to engage in high-risk practices and that despite HIV/AIDS
knowledge; young people underestimate their own risk of becoming
infected with HIV. However, transmission of HIV between intravenous
drug users has clearly decreased, and HIV transmission by blood
transfusion has become quite rare in developed countries.

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 AIDS is now a pandemic, with an estimated 38.6 million people now
living with the disease worldwide. Sub-Saharan Africa remains by far the
worst affected region, with an estimated 21.6 to 27.4 million people
currently living with HIV. Two million of them are children younger than
15 years of age. More than 64% of all people living with HIV are in sub-
Saharan Africa, as are more than three quarters (76%) of all women living
with HIV. In 2005, there were 12.0 million AIDS orphans living in sub-
Saharan Africa 2005. South and South East Asia are second worst affected
with 15%. AIDS accounts for the deaths of 500,000 children in this region.
Two-thirds of HIV/AIDS infections in Asia occur in India, with an
estimated 5.7 million infections (0.9% of population), surpassing South
Africa's estimated 5.5 million (11.9% of population) infections, making it
the country with the highest number of HIV infections in the world. In the
35 African nations with the highest prevalence, average life expectancy is
48.3 years — 6.5 years less than it would be without the disease.
HIV and AIDS retard economic growth by destroying human capital.
The World Health Organization has predicted outcomes for sub-Saharan
Africa to the year 2025. These range from a plateau and eventual decline
in deaths beginning around 2012 to a catastrophic continual growth in the
death rate with potentially 90 million cases of infection. Without proper
nutrition, health care and medicine that is available in developed countries,
large numbers of people in these countries is falling victim to AIDS. They
will not only be unable to work, but will also require significant medical
care. The forecast is that this will likely cause a collapse of economies and
societies in the region. In some heavily infected areas, the epidemic has
left behind many orphans cared for by elderly grandparents.
By killing off mainly young adults, AIDS seriously weakens the
taxable population, reducing the resources available for public
expenditures such as education and health services not related to AIDS
resulting in increasing pressure for the state's finances and slower growth

104
of the economy. This results in a slower growth of the tax base, an effect
that will be reinforced if there are growing expenditures on treating the
sick, training (to replace sick workers), sick pay and caring for AIDS
orphans. This is especially true if the sharp increase in adult mortality
shifts the responsibility and blame from the family to the government in
caring for these orphans. On the level of the household, AIDS results in
both the loss of income and increased spending on healthcare by the
household. The income effects of this lead to spending reduction as well as
a substitution effect away from education and towards healthcare and
funeral spending.
From the moment scientists identified HIV and AIDS, social
responses of fear, denial, stigma and discrimination have accompanied the
epidemic. Discrimination has spread rapidly, fuelling anxiety and
prejudice against the groups most affected, as well as those living with
HIV or AIDS. It goes without saying that HIV and AIDS are as much
about social phenomena as they are about biological and medical concerns.
Across the world the global epidemic of HIV/AIDS has shown itself
capable of triggering responses of compassion, solidarity and support,
bringing out the best in people, their families and communities. But the
disease is also associated with stigma, repression and discrimination, as
individuals affected by HIV have been rejected by their families, their
loved ones and their communities. This rejection holds as true in the rich
countries of the north as it does in the poorer countries of the south.
In many societies people living with HIV and AIDS are often seen as
shameful. In some societies the infection is associated with minority
groups or behaviors, for example, homosexuality. In some cases
HIV/AIDS may be linked to «perversion» and those infected will be
punished. Also, in some societies HIV/AIDS is seen as the result of
personal irresponsibility. Sometimes, HIV and AIDS are believed to bring
shame upon the family or community. And whilst negative responses to

105
HIV/AIDS unfortunately widely exist, they often feed upon and reinforce
dominant ideas of good and bad with respect to sex and illness, and proper
and improper behaviors.
AIDS stigma exists around the world in a variety of ways, including
ostracism, rejection, discrimination and avoidance of HIV infected people;
compulsory HIV testing without prior consent or protection of
confidentiality; violence against HIV infected individuals or people who
are perceived to be infected with HIV; and the quarantine of HIV infected
individuals. Often, AIDS stigma is expressed in conjunction with one or
more other stigmas, particularly those associated with homosexuality,
bisexuality, and intravenous drug use.
The majority of medical workers believe that the major requirement
of coping with the AIDS pandemic is following the 4 ethical principles:
respect, mercy, justice and the no harm principle.
Respect – treating a patient like a separate self-sufficient individual able to
exercise control over his life. It includes the observance of the right to
have one's private life and the principle of the «informed consent».
No Harm principle – restricting the patient's behavior in cases of
threatening health of surrounding people.
Mercy – implies that medical workers carefully act for the good of the
patients for example warning them before carrying out tests and politely
telling them the results with psychological aid if needed.
Justice equal distribution of responsibilities between the individual and
the society, rejecting all forms of discrimination and encouraging any
support to medical institutions from other authorities
The task of the modern Medical Ethics is to correctly and accurately
formulate legal aspects of AIDS, the most important of which are the
following:
1. Is it legally correct to examine each individual (AIDS) as it can cause
some psychological damage to the patient in case of mistakes?

106
2. In a number of countries infected people are not allowed to cross their
border, but on the other side such decision restricts democratic freedoms.
3. If infected people are not allowed to take up most jobs, which keep the
society safe, how are they supposed to learn their living during for
example a 10 year long latent period?
4. Another burning problem is the forced isolation of the infected people,
still no state is able to provide proper safe isolation for the patients,
moreover it contradicts humanism. But many people insist on the
inevitable forced isolation of the infected, as the most effective measures.
It may be explained by the fact that having all the legal responsibility on
themselves, the infected are not always cautious enough with the contacts
with healthy people. One of the ways out is to organize voluntary hospices
for the infected people, where they can lead normal life not limited in
contacts with each other.
5. There are cases when people are infected with AIDS intentionally for
the purpose of revenge or blackmail.
6. Many reports reveal the extent to which people are stigmatized and
discriminated against by health care systems. Many studies reveal the
reality of withheld treatment, non-attendance of hospital staff to patients,
HIV testing without consent, lack of confidentiality and denial of hospital
facilities and medicines. Also fuelling such responses are ignorance and
lack of knowledge about HIV transmission.
A survey conducted in 2002, among some 1,000 physicians, nurses
and midwives in four Nigerian states, returned disturbing findings. One in
10 doctors and nurses admitted having refused to care for an HIV/AIDS
patient or had denied HIV/AIDS patients admission to a hospital. Almost
40% thought a person's appearance betrayed his or her HIV-positive status,
and 20% felt that people living with HIV/AIDS had behaved immorally
and deserved their fate. One factor fuelling stigma among doctors and
nurses is the fear of exposure to HIV as a result of lack of protective

107
equipment. Also at play, it appears was the frustration at not having
medicines for treating HIV/AIDS patients, who therefore were seen as
'doomed' to die.
7. Lack of confidentiality has been repeatedly mentioned as a particular
problem in health care settings. Many people living with HIV/AIDS do not
get to choose how, when and to whom to disclose their HIV status. When
surveyed recently, 29% of persons living with HIV/AIDS in India, 38% in
Indonesia, and over 40% in Thailand said their HIV-positive status had
been revealed to someone else without their consent. Huge differences in
practice exist between countries and between health care facilities within
countries. In some hospitals, signs have been placed near people living
with HIV/AIDS with words such as 'HIV-positive' and 'AIDS' written on
them.
HIV-related stigma and discrimination remains an enormous barrier
to effectively fighting the HIV and AIDS epidemic. Fear of discrimination
often prevents people from seeking treatment for AIDS or from admitting
their HIV status publicly. People with (or suspected of having) HIV may
be turned away from healthcare services, employment, refused entry to
foreign country. In some cases, they may be evicted from home by their
families and rejected by their friends and colleagues. The stigma attached
to HIV/AIDS can extend into the next generation, placing an emotional
burden on those left behind. Denial goes hand in hand with discrimination,
with many people continuing to deny that HIV exists in their communities.
Today, HIV/AIDS threatens the welfare and well being of people
throughout the world. At the end of the year 2005, 40.3 million people
were living with HIV or AIDS and during the year 3.1 million died from
AIDS-related illness. Combating the stigma and discrimination against
people who are affected by HIV/AIDS is as important as developing the
medical cures in the process of preventing and controlling the global
epidemic.

108
 So how can progress be made in overcoming this stigma and
discrimination? How can we change people attitudes to AIDS? A certain
amount can be achieved through the legal process. In some countries
people who are living with HIV or AIDS lack knowledge of their rights in
society. They need to be educated, so they are able to challenge the
discrimination, stigma and denial that they meet in society. Institutional
and other monitoring mechanisms can enforce the rights of people living
with HIV or AIDS and provide powerful means of mitigating the worst
effects of discrimination and stigma.
However, no policy or laws can alone combat HIV/AIDS related
discrimination. The fear and prejudice that lies at the core of the
HIV/AIDS discrimination needs to be tackled at the community and
national levels. A more enabling environment needs to be created to
increase the visibility of people with HIV/AIDS as a «normal» part of any
society. In the future, the task is to confront the fear based messages and
biased social attitudes, in order to reduce the discrimination and stigma of
people who are living with HIV or AIDS.
The further spread of AIDS can only be halted by means of global
education about the disease and how it is contrasted. Because the AIDS
epidemic has developed as a social phenomenon as well as a disease, the
response to it has been social as well as medical.

TRANSPLANTOLOGY
I. Bioethical Issues of Organ Donation.
II. Ethical Problems of Procurement and Distribution.
III. Social Issues of Organ Transplantation.

Literature
Arthur L. Caplan, Daniel H. Coelho The Ethics of Organ Transplants: The
Current Debate. Prometheus Books, 1998.

109
Finn, R. Organ Transplants: Making the Most of Your Gift of Life.
Sebastopol: O'Reilly & Associates. 2000.
Lock, M. Twice Dead: Organ Transplants and the Reinvention of Death.
Berkeley, CA: University of California Press. 2002.
Organ and Tissue Donation: Ethical, Legal, and Policy Issues. Carbondale:
Southern Illinoios University Press, 1996.

Reports, synopses, course and term paper

Political issues of organ transplantation.
Future of transplantation.
Psychological problems of xenotransplantation.
Danger of commerce of transplantation.

Organ transplantation is an area where progress has been astounding

but where ethical reflection has arisen more questions then answers. Ever
since its inception in the 1950s, organ transplantation has been
accompanied by many hard issues about the ethics of taking organs from
the dead and the living and giving them to others. It has been one of the
most fertile sources of discussion among physicians, ethicists, policy
makers. What are the sources of organs used in transplantation? How can
we make the procurement system more efficient? Should we pay for
organs? Should someone who has already received one transplant be
allowed a second? Should alcoholics be given liver transplants? Are
transplants really worth the tremendous costs?
Modern bioethicists disagree on the moral status of organ donation.
Certain groups, like the traditional Jews oppose organ donation on
religious grounds. Issues of patient autonomy, living wills and
guardianship are in the focus of discussion about organ transplantation. It
is possible that a compelling state interest overrules any patient’s right to
autonomy.
From a philosophical standpoint, the primary issues of the morality

110
of organ donation are definition of life, death, human and body. For
example, whether or not a brain-dead patient ought to be kept artificially
animate in order to preserve organs for harvesting is an ongoing problem
in clinical bioethics.
Lying at the heart of most of these ethical debates are the twin
questions of procurement and distribution. How do we get organs, and
how do we decide who will receive the implants? There are always fewer
donors than there are potential recipients, and that's why some 5,000
people die every year while waiting for new organs.
For a variety of clinical and social reasons, however, not all potential
donors become actual donors. For example, some organs, though procured,
are not transplanted because after removal they are found to be damaged.
In addition, roughly one-third of the time health care professionals fail to
offer family members the opportunity to donate; and in another third,
although families are asked to donate the organs, they decline to donate for
a number of reasons. Consistently fewer organs are available for
transplantation than are needed to meet demand. For example, despite the
dramatic increase in the number of heart transplants performed, only a
small fraction of persons who could potentially benefit from a heart
transplant actually receives one. The shortage of donor hearts is especially
acute for children in their first year who might benefit from transplants. As
transplant procedures become more successful, candidate selection criteria
become less restrictive, creating a corresponding increase in the number of
candidates. Though not all persons who could potentially benefit from a
transplant are placed on waiting lists, increases in the pool of persons
wanting transplants reflect the impact of rising success rates. In sum,
chronic shortages characterize the field of organ transplantation today and
will continue to do so for the foreseeable future.
Furthermore, organ procurement raises ethical concerns about the
determination of death that have been partly addressed by legislation that
defines it as brain death. It can also create conflict or the appearance of

111
conflict between the care of a potential donor and the needs of a potential
recipient. The care of the potential donor must be kept separate from the
care of a recipient. The potential donor's physician should not be
responsible for the care of the recipient nor be involved in retrieving the
organs or tissue. However, the potential donor's physician may alert an
organ-tissue procurement team of the existence of a potential donor. Once
brain death has occurred and organ donation is authorized, the donor's
physician should know how to maintain the viability of organs and tissues
in coordination with the procurement team. Before declaration of the brain
death, treatments proposed to maintain the function of transplantable
organs may be used only if they are not expected to harm the potential
donor, whether by causing symptoms or by compromising the chance of
survival.
And what about the question of consent? Right now, someone has to
directly agree for transplantation in order for organs to be removed - but
should the policy be changed so that the consent is automatically assumed
unless someone says «no»? Because most people can live just fine with
only one kidney, it is something which can be donated while you are still
alive - but should you be allowed to sell it, or is it not possible for there to
be genuine consent in such a grave matter?
The shortage of transplantable organs naturally gives rise to
questions about the most ethical methods for distributing this scarce
resource. Determining who gets organs involves selection decisions at two
distinct levels – placing potential recipients for organ transplantation on a
waiting list, and then selecting a recipient from the waiting list when an
organ becomes available. Different criteria can determine referral patterns
for consideration for a transplant or for placement on a particular center's
waiting list. Typically, a transplant center's interdisciplinary team does an
initial evaluation of the newly referred patient based on objective medical
criteria such as the diagnosis, extent of disease, and probability of success.
In some circumstances, financial and social factors may also be considered

112
relevant factors. One commentator notes that «age, geography, ability to
pay, patient and referring doctor perseverance, if someone is an interesting
or unusual case, if someone has the disease qualifications to enter into an
ongoing research study, the presence of disability or mental illness, the
availability of a supportive family, and having a good psychological
profile, including the right attitude, all play important roles».
The relevance of factors like a patient’s family situation to the
prospects for success are widely recognized, but there is disagreement
about whether, or to what extent, this should influence decisions about
whether to list a patient for transplant. Nevertheless, there is general
agreement that candidate selection from a waiting list should be primarily
based on medical criteria, and that race, gender, economic status and other
demographic criteria which are not directly related to the individual
patient’s medical condition are inappropriate.
Different kinds of medical criteria, however, may lead to different
decisions.
One set of criteria represents the urgency of medical need, and reflects the
ethical value of compassion for those who suffer. Employing this standard,
we would give priority to the patients with the most pressing need for a
transplant, that is, to the patients whose diseased organs are the nearest to
complete failure. An alternative set of criteria, reflecting the ethical value
of utility, would lead to selection of patients with the most favorable
posttransplant prognosis. The tension between these criteria may be
inescapable, and is especially apparent in cases when a patient is being
considered for cardiac retransplantation, since survival rates for a second
transplant are significantly lower than for initial transplants. This has led
some to argue that it would be unfair for one individual to be given two or
even more chances while others are still awaiting their first chance for the
same organ.
United Network for Organ Sharing gives somewhat greater emphasis
to criteria such as urgency of need and time spent on the waiting list than

113
to criteria reflecting the medical benefits likely to accrue to transplant
recipients. Depending on which medical criteria the transplant center uses,
when an organ becomes available through the organ distribution network,
it is usually the patient highest on the waiting list with suitable tissue and
blood type who receives the transplant.
Other factors which have been thought relevant to determining
whether a patient should be eligible for organ transplant, such as whether
alcoholics should receive liver transplants, whether incarcerated criminals
or patients with a history of attempted suicide should be eligible, are more
controversial.
It has also been suggested that eligibility for transplants should be
linked directly to donor status, so only registered donors would be able to
receive transplanted organs. Many have argued, however, that even the
category of medical criteria is poorly defined. Do medical criteria, for
example, include the existence of a family or social network of support for
the patient, which may increase the probability of a successful outcome?
To minimize subjective selection factors, it has been suggested that once a
waiting list is established (based on medical and, perhaps, other criteria),
the final selection from equally eligible patients should be made on the
basis of chance.
Suggested decision makers at both selection levels include third party
payers, referring physicians, transplant teams, and appropriately
constituted committees. Each of these alternatives raises concerns; for
example, can physicians be asked to make these rationing choices without
undermining the patient-physician relationship? Can committees overcome
the biases of their membership?
No agreement has been reached on who the decision makers should
be, but there is consensus that they must be held accountable and that
whatever selection process is used it must be equitable.
The importance of public perceptions of the field of transplant
medicine has been underscored by reports of prominent public figures

114
receiving transplants within a very short time after being listed as
candidates. Since patients frequently wait several months for a transplant,
these episodes prompted questions about fairness and favoritism in the
selection process. If the public does not believe the process is fair, support
for altruistic donation of organs and continued commitment of funds to
pay for transplants may be seriously eroded.
Organ donation is fast becoming an important bioethical issue from
a social perspective as well. While most first-world nations have a legal
system of oversight for organ transplantation, the fact remains that demand
far outstrips supply. Consequently, there has arisen a possibility to the
transplant trade. In many cases, those in need of organs are put on waiting
lists for legal organs for indeterminate lengths of time - many die while
still on a waiting list.
On the one hand are those who contend that those who can afford to
buy organs are «exploiting» those who are desperate enough to sell their
organs? Many suggest this results in a growing inequality of status
between the rich and the poor. On the other hand are those who contend
that the desperate should be allowed to sell their organs, and that stopping
them is merely contributing to their status as impoverished? Further, those
in favor of the trade hold that «exploitation» is morally preferable to
«death», and insofar as the choice lies between abstract notions of
«justice» on the one hand and a dying person desperately in need of an
organ on the other hand, the organ trade should be legalized.
Proponent of legalization claim, that legalization of the organ trade
carries with it its own sense of «justice» as well. Continuing black-market
trade creates further disparity on the demand side: only the rich can afford
such organs. Legalization of the international organ trade would lead to
increased supply, lowering prices so that the poor might be able to afford
such organs as well.
Exploitation arguments generally come from two main areas:
Physical exploitation suggests that the operations in question are

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quite risky, and, taking place in third-world hospitals or «back-alleys»,
even more risky. Yet, if the operations in question can be made safe, there
is little threat to the donor.
Financial exploitation suggests that the donors are not paid
«enough». This argument generally relies upon the assumption that there
exists some financial amount that does indeed constitute «enough», but
that the donors in question are not receiving this amount of money in
return.
If, however, neither of the above arguments are valid, the act
generally cannot be condemned on a utilitarian basis.

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 Glossary

Abortion is voluntary or induced termination of pregnancy.

Acquired Immune Deficiency Syndrome is a collection of symptoms

and infections in humans resulting from the specific damage to the
immune system caused by the human immunodeficiency virus (HIV).

Аpplied ethics is the branch of ethics which consists of the analysis of

specific, controversial moral issues.

Artificial insemination is when sperm is placed into a female’s uterus

using artificial means rather than by sexual intercourse. Semen from the
father or donor is injected directly into woman uterus to improve the
chance of conception in a process called intrauterine insemination.

Bioethics is a term, which was first used by biologist Van Rensselaer

Potter, referred to a new field devoted to human survival and an imported
quality of life, not necessarily or particularly medical in character.

Cloning an organism means to create a new organism with the same

genetic information as an existing one.

Confidentiality is a fundamental tenet of medical care. It is a matter of

respecting the privacy of patients, encouraging them to seek medical care
and discuss their problems candidly, and preventing discrimination on the
basis of their medical conditions.

Deontology is any position in ethics which claims that the rightness or

wrongness of actions depends on whether they correspond to our duty or
not. The word derives from the Greek word for duty, deon.

Ethics is a general term for what is often described as the «science of

morality».

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Euthanasia originates from the Greek language: «eu» means «good» and
«thanatos» means «death». One meaning given to the word is «the
intentional termination of life by another at the explicit request of the
person who dies».

Genetics is the study of genes and their role in inheritance.

Human Genome Project (HGP) is one of the scientific projects with the
aim to decipher the entire genetic code of human beings.

Informed consent is the obligation of physicians or researchers to allow

patients or subjects to be active participants in decision regarding their
care or participation in research.

In vitro fertilization (IVF) is a technique in which eggs are fertilized

outside the woman’s body.

Morality is a complex of principles based on cultural, religious, and

philosophical concepts and beliefs.

Metaethics is the study of the origin and meaning of ethical concepts.

Normative ethics is examination of the adequacy of moral or ethical
values, standards or judgments.

Palliative care and hospice are frequently used interchangeably to

describe an approach to the care of individuals who are likely to die in the
relatively near future from serious, incurable disease, for whom the
principal focus of care is quality of life and support for the patient's
family.

The principle of nonmaleficence requires of physician that he/she not

intentionally create a needless harm or injury to the patient, either through
acts of commission or omission.

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119
The principle of beneficence expresses the concept that professionals
have a duty to act for the benefit of others. Under this principle, the
physician’s primary obligation is service to the patient and the public-at-
large.

The principle of respect for autonomy means that the patient has the
capacity to act intentionally, with understanding, and without controlling
influences that would mitigate against a free and voluntary act.

The principle of justice expresses the concept that professionals have a

duty to be fair in their dealings with patients, colleagues and society.
Under this principle, the physician's primary obligations include dealing
with people justly and delivering health care without prejudice.

Physician assistant suicide — a doctor provides a patient with the means

to end his own life (e.g. a prescription for lethal dose of sleeping pills), but
the doctor does not administer it.

A surrogate mother or ersatz mother is a woman who carries a child for a

couple or single person with the intention of giving that child up once it is
born. The surrogate mother may be the baby's biological mother
(traditional surrogacy) or she may be implanted with someone else's
fertilized egg (gestational surrogacy).

Suicide is the act of intentionally ending one’s own life.

Truth-telling information is requirement of honesty, clearly linked today

with the patient's new legal right to give informed and free consent or
refusal of treatment.

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 Questions for self-control
1. Ethics: definition and divisions.
2. Bioethics.
3. Ethic codes.
4. The principle of nonmaleficence.
5. The principle of beneficence.
6. The principle of respect for autonomy.
7. The principle of justice.
8. Informed consent.
9. Confidentiality.
10. Truth-telling information.
11. Trust between patient and providers.
12. The definitions of pregnancy, miscarriage and abortion.
13. The main positions for abortion.
14. Religion and cultural attitudes to abortion.
15. Artificial insemination.
16. In vitro fertilization.
17. Surrogate mother.
18. Basic bioethical principles related to modern reproductive
technologies.
19. The definition and classification of euthanasia.
20. Euthanasia: pros & cons.
21. Legislation and national political movements.
22. The definition of suicide.
23. Causes of suicide.
24. Suicide: philosophical views.
25. Suicide: religious views.
26. The development of palliative care.
27. Ethical and policy issues in palliative care and hospice.
28. Specific features of ethical problems in genetics.

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 29. Ethical problems of genetic testing.
30. Cloning.
31. The AIDS pandemic.
32. The problem of AIDS/HIV origin. Principal ways of transmission.
33. Social and psychological consequences of the AIDS pandemic. AIDS
stigma.
34. AIDS - infected people and medical ethics.
35. Legal issues of AIDS.
36. Bioethical issues of organ donation.
37. Ethical problems of procurement and distribution of transplantation.
38. Social issues of organ transplantation.

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 TESTS

FINISH THE SENTENCE

Ethics is a general term for what is often described as …… .
1) the «science of morality»; 2) the study of value; 3) the theory of reality

PLEASE CHOOSE THE RIGHT ANSWER FROM GIVEN BELOW

Suicide is the act of …… ending one’s own life.
1) intentional; 2) involuntary; 3) inadvertent

FINISH THE SENTENCE

Аpplied ethics is the branch of ethics which consists of the analysis of
specific, …. .
1) controversial moral issues; 2) philosophical conceptions; 3)
controversial political issues.

FINISH THE SENTENCE

Examination of the adequacy of moral or ethical values, standards or
judgments is … .
1) normative ethics; 2) metaethics; 3) bioethics.

PLEASE CHOOSE THE RIGHT ANSWER FROM GIVEN BELOW

Morality is a complex of principles based on …… concepts and
beliefs.
1) cultural; 2) religious; 3) philosophical; 4) cultural, religious, and
philosophical.

PLEASE CHOOSE THE RIGHT ANSWER FROM GIVEN BELOW

Abortion is ….. termination of pregnancy.
1) voluntary; 2) induced; 3) voluntary or induced.

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 FINISH THE SENTENCE
Aquinas advances three moral arguments against suicide in … .
1) «Summa Theologica»; 2) «On Suicide»; 3) «Suicide: A Study in
Sociology»;

PLEASE CHOOSE THE RIGHT ANSWER FROM GIVEN BELOW

The Principle of Respect for Autonomy — … .
1) the patient has the right to refuse or choose their treatment; 2) concerns
the distribution of scarce health resources; 3) a practitioner should act in
the best interest of the patient.

PLEASE CHOOSE THE RIGHT ANSWER FROM GIVEN BELOW

Information Element of informed consent is …
1) disclosure; 2) competence 3) decision.

FINISH THE SENTENCE

The main object of medical deontology are the relationships between …. .
1) the doctor and the patient; 2) the patient and patient `s family.

FINISH THE SENTENCE

Conventionally in modern bioethics we can find three main positions for
abortion:
liberal, medium and … .
1) conservative; 2) cultural.

PLEASE CHOOSE THE RIGHT ANSWER FROM GIVEN BELOW

Passive euthanasia is … .
1) usually defined as withdrawing medical treatment; 2) taking specific
steps to cause the patient's death.

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PLEASE CHOOSE THE RIGHT ANSWER FROM GIVEN BELOW
… has become the first country in the world to legalize euthanasia.
1) The Netherlands; 2) The Belgian; 3) The Russia.

PLEASE CHOOSE THE RIGHT ANSWER FROM GIVEN BELOW

The term «hospice» was first applied to specialized care for dying patients
in … by physician Dame Cicely Saunders.
1) 1967; 2) 1984; 3) 1476.

FINISH THE SENTENCE

The Nuremberg Code is … .
1) a set of principles for human experimentation. 2) a declaration
adopted by the United Nations General Assembly, outlining basic human
rights.

PLEASE CHOOSE THE RIGHT ANSWER FROM GIVEN BELOW

… is a collection of symptoms and infections in humans resulting from
the specific damage to the immune system.
1) AIDS; 2) HIV; 3) Flu.

PLEASE CHOOSE THE RIGHT ANSWER FROM GIVEN BELOW

…. is the process of creating an identical copy of an original.
1) Cloning; 2) Genetic testing.

PLEASE CHOOSE THE RIGHT ANSWER FROM GIVEN BELOW

The … model for the physician-patient relationship involved patient
dependence on the physician's professional authority.
1) collegiate; 2) technical; 3) paternalistic.

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PLEASE CHOOSE THE RIGHT ANSWER FROM GIVEN BELOW
The subjects of medical research must be volunteers ... in the research
project.
1) or necessary participants; 2) and informed participants.

PLEASE CHOOSE THE RIGHT ANSWER FROM GIVEN BELOW

The duty of the physician … in medical research.
1) to protect the life, health, privacy, and dignity of the human subject; 2)
to protect interests of science; 3) to protect interests of state.

FINISH THE SENTENCE

The World Medical Association has developed the Declaration of Helsinki
as a statement of ethical principles to provide guidance to physicians and
other participants in medical research … .
1) involving human subjects; 2) involving animals.

BASIC RESOURCES IN BIOETHICS

On-line resources
Kennedy Institute of Ethics
http://www.georgetown.edu/research/kie/
The Kennedy Institute of Ethics is a teaching and research center offering
ethical perspectives on major policy issues. It's noted as being the "largest
university based group of faculty members in the world devoted to
research and teaching in biomedical ethics and other areas of applied
ethics".

Johns Hopkins University Bioethics Institute

http://www.hopkinsmedicine/bioethics/
The Bioethics Institute was established in 1995 as a way to promote

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research in bioethics. In addition to information regarding the Institute, this
site also has related links to other bioethics information sources.
The Online Ethics Center for Engineering & Science
http://onlineethics.org/
This site is designed to provide engineers, scientists, and science and
engineering students with resources useful for understanding and
addressing ethical issues. This Center is virtually located on the campus of
Case Western Reserve University.

Ethics Updates
http://www.ethics. sandiego. edu/index/html/
Ethics Updates is designed primarily to be used by ethics instructors and
their students. It is intended to provide updates on current literature, both
popular and professional, that relates to ethics.

Applied Ethics Resources on www…

http://www.ethicsweb.ca/resources/
The site contains references to resources on ethics of business, ethics of
public health services, ethics of research and professional ethics. All
resources are systematized.

The Hastings Center for Bioethics

http://www.thehastingscenter.org/
The Hastings Center main focus is the fundamental ethical issues in health,
medicine and the environment and how these issues affect people. In
addition to educational opportunities and research programs offered at the
Center, their Morrison Library offers bioethics related information online.

The American Journal of Bioethics & bioethics.net

http://bioethics.net/

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This is a University of Pennsylvania Center for Bioethics site that provides
lots of links to useful background information on various topics in
bioethics.

Graduate Programs in Bioethics/Medical Humanities

http://apa. udel. edu/ apa/ governance/ committees/ medicine/
Various bioethics programs available in universities in the U.S., Canada,
and Australia.

Bioethics Case Studies

http://www.mhhe.com/biosci/genbio/olc_linkedcontent/bioethics_cases/ind
ex.html
Ronnee Yashon, an expert in teaching genetics, ethics and law, developed
the 20 different cases studies for this McGraw-Hill site that includes topics
ranging from cloning to organ donation to DNA forensics.

UB Center for Clinical Ethics and Humanities in Health Care

http://www.wings. buffalo edu/faculty/research/bioethics/index.html
An interdisciplinary academic center at the University of Buffalo. Includes
resources produced by the UB center as well as links to worldwide
information.

Human Genome Project Information - Ethical, Legal and Social Issues

http://www.genome.
National Human Genome Research Institute
The U.S. Department of Energy (DOE) and the National Institutes of
Health (NIH) have devoted 3% to 5% of their annual Human Genome
Project (HGP) budgets toward studying the ethical, legal, and social issues
(ELSI) surrounding availability of genetic information. This represents the

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world's largest bioethics program, which has become a model for ELSI
programs around the world.

Bioethics today
http://www.shef. ac. uk/ bioethics-today/
Bioethics from a UK/European perspective.

JOURNALS AND NEWSLETTERS

American Journal of Law and Medicine
Bioethics
Cambridge Quarterly of Health Care Ethics
Hastings Center Report
Health Care Analysis: Journal of Philiosophy and Policy
HEC (Healthcare Ethics Committee) Forum
IRB: Review of Human Subjects Research
International Journal of Bioethics/Journal International de Bioéthique
Issues in Law and Medicine
Journal of Clinical Ethics
Journal of Contemporary Health Law and Policy
Journal of Health Politics, Policy and Law
Journal of Law, Medicine and Ethics
Journal of Medical Ethics
Journal of Medical Humanities
Journal of Medicine and Philosophy
Kennedy Institute of Ethics Journal
Linacre Quarterly
Philosophy and Public Affairs
Second Opinion
Social Science and Medicine
Theoretical Medicine

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 APPENDIX
THE OATH OF HIPPOCRATES
I SWEAR by Apollo the physician and AEsculapius, and Health, and All-
heal, and all the gods and goddesses, that, according to my ability and
judgement, I will keep this Oath and this stipulation — to reckon him who
taught me this Art equally dear to me as my parents, to share my substance
with him, and relieve his necessities if required; to look upon his offspring
in the same footing as my own brothers, and to teach them this art, if they
shall wish to learn it, without fee or stipulation; and that by precept,
lecture, and every other mode of instruction, I will impart a knowledge of
the Art to my own sons, and those of my teachers, and to disciples bound
by a stipulation and oath according to the law of medicine, but to none
others. I will follow that system of regimen which, according to my ability
and judgement, I consider for the benefit of my patients, and abstain from
whatever is deleterious and mischievous. I will give no deadly medicine to
any one if asked, nor suggest any such counsel; and in like manner I will
not give to a woman a pessary to produce abortion. With purity and with
holiness I will pass my life and practice my Art. I will not cut persons
labouring under the stone, but will leave this to be done by men who are
practitioners of this work. Into whatever houses I enter, I will go into them
for the benefit of the sick, and will abstain from every voluntary act of
mischief and corruption; and, further, from the seduction of females or
males, of freemen and slaves. Whatever, in connection with my
professional service, or not in connection with it, I see or hear, in the life
of men, which ought not to be spoken of abroad, I will not divulge, as
reckoning that all such should be kept secret. While I continue to keep this
Oath unviolated, may it be granted to me to enjoy life and the practice of
the art, respected by all men, in all times. But should I trespass and violate
this Oath, may the reverse be my lot.

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 THE DECLARATION OF GENEVA

The Declaration of Geneva was adopted by the General Assembly of the

World Medical Association at in 1948 and amended by the 22d World
Medical Assembly at Sydney in 1968. It is a declaration of physicians'
dedication to the humanitarian goals of medicine, a declaration that was
especially important in view of the medical crimes which had just been
committed in Nazi Germany. The Declaration of Geneva was intended to
update the Oath of Hippocrates , which was no longer suited to modern
conditions.
The Declaration of Geneva reads «AT THE TIME OF BEING
ADMITTED AS A 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, even after the
patient has died;
I WILL MAINTAIN by all the means in my power, the honor and the
noble traditions of the medical profession;
MY COLLEAGUES will be my sisters and brothers;
I WILL NOT PERMIT considerations of age, disease or disability, creed,
ethnic origin, gender, nationality, political affiliation, race, sexual
orientation, or social standing to intervene between my duty and my
patient;
I WILL MAINTAIN the utmost respect for human life from its beginning
even under threat and I will not use my medical knowledge contrary to the
laws of humanity;
I MAKE THESE PROMISES solemnly, freely and upon my honor.»

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 WORLD MEDICAL ASSOCIATION
DECLARATION OF HELSINKI

 Ethical Principles for Medical Research Involving Human Subjects

Adopted by the 18th WMA General Assembly
Helsinki, Finland, June 1964
and amended by the
29th WMA General Assembly, Tokyo, Japan, October 1975
35th WMA General Assembly, Venice, Italy, October 1983
41st WMA General Assembly, Hong Kong, September 1989
48th WMA General Assembly, Somerset West, Republic of South Africa,
October 1996
and the
52nd WMA General Assembly, Edinburgh, Scotland, October 2000
А. INTRODUCTION
1. The World Medical Association has developed the Declaration of
Helsinki as a statement of ethical principles to provide guidance to
physicians and other participants in medical research involving human
subjects. Medical research involving human subjects includes research on
identifiable human material or identifiable data.
2. It is the duty of the physician to promote and safeguard the health of the
people. The physician's knowledge and conscience are dedicated to the
fulfillment of this duty.
3. The Declaration of Geneva of the World Medical Association binds the
physician with the words, «The health of my patient will be my first
consideration», and the International Code of Medical Ethics declares that,
«A physician 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».

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4. Medical progress is based on research which ultimately must rest in part
on experimentation involving human subjects.
5. In medical research on human subjects, considerations related to the
well-being of the human subject should take precedence over the interests
of science and society.
6. The primary purpose of medical research involving human subjects is to
improve prophylactic, diagnostic and therapeutic procedures and the
understanding of the aetiology and pathogenesis of disease. Even the best
proven prophylactic, diagnostic, and therapeutic methods must
continuously be challenged through research for their effectiveness,
efficiency, accessibility and quality.
7. In current medical practice and in medical research, most prophylactic,
diagnostic and therapeutic procedures involve risks and burdens.
8. Medical research is subject to ethical standards that promote respect for
all human beings and protect their health and rights. Some research
populations are vulnerable and need special protection. The particular
needs of the economically and medically disadvantaged must be
recognized. Special attention is also required for those who cannot give or
refuse consent for themselves, for those who may be subject to giving
consent under duress, for those who will not benefit personally from the
research and for those for whom the research is combined with care.
9. Research Investigators should be aware of the ethical, legal and
regulatory requirements for research on human subjects in their own
countries as well as applicable international requirements. No national
ethical, legal or regulatory requirement should be allowed to reduce or
eliminate any of the protections for human subjects set forth in this
Declaration.
В. BASIC PRINCIPLES FOR ALL MEDICAL RESEARCH
10. It is the duty of the physician in medical research to protect the life,
health, privacy, and dignity of the human subject.
11. Medical research involving human subjects must conform to generally

133
accepted scientific principles, be based on a thorough knowledge of the
scientific literature, other relevant sources of information, and on adequate
laboratory and, where appropriate, animal experimentation.
12. Appropriate caution must be exercised in the conduct of research
which may affect the environment, and the welfare of animals used for
research must be respected.
13. The design and performance of each experimental procedure involving
human subjects should be clearly formulated in an experimental protocol.
This protocol should be submitted for consideration, comment, guidance,
and where appropriate, approval to a specially appointed ethical review
committee, which must be independent of the investigator, the sponsor or
any other kind of undue influence. This independent committee should be
in conformity with the laws and regulations of the country in which the
research experiment is performed. The committee has the right to monitor
ongoing trials. The researcher has the obligation to provide monitoring
information to the committee, especially any serious adverse events. The
researcher should also submit to the committee, for review, information
regarding funding, sponsors, institutional affiliations, other potential
conflicts of interest and incentives for subjects.
14. The research protocol should always contain a statement of the ethical
considerations involved and should indicate that there is compliance with
the principles enunciated in this Declaration.
15. Medical research involving human subjects should be conducted only
by scientifically qualified persons and under the supervision of a clinically
competent medical person. The responsibility for the human subject must
always rest with a medically qualified person and never rest on the subject
of the research, even though the subject has given consent.
16. Every medical research project involving human subjects should be
preceded by careful assessment of predictable risks and burdens in
comparison with foreseeable benefits to the subject or to others. This does
not preclude the participation of healthy volunteers in medical research.

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The design of all studies should be publicly available.
17. Physicians should abstain from engaging in research projects involving
human subjects unless they are confident that the risks involved have been
adequately assessed and can be satisfactorily managed. Physicians should
cease any investigation if the risks are found to outweigh the potential
benefits or if there is conclusive proof of positive and beneficial results.
18. Medical research involving human subjects should only be conducted
if the importance of the objective outweighs the inherent risks and burdens
to the subject. This is especially important when the human subjects are
healthy volunteers.
19. Medical research is only justified if there is a reasonable likelihood
that the populations in which the research is carried out stand to benefit
from the results of the research.
20. The subjects must be volunteers and informed participants in the
research project.
21. The right of research subjects to safeguard their integrity must always
be respected. Every precaution should be taken to respect the privacy of
the subject, the confidentiality of the patient's information and to minimize
the impact of the study on the subject's physical and mental integrity and
on the personality of the subject.
22. In any research on human beings, each potential subject must be
adequately informed of the aims, methods, sources of funding, any
possible conflicts of interest, institutional affiliations of the researcher, the
anticipated benefits and potential risks of the study and the discomfort it
may entail. The subject should be informed of the right to abstain from
participation in the study or to withdraw consent to participate at any time
without reprisal. After ensuring that the subject has understood the
information, the physician should then obtain the subject's freely-given
informed consent, preferably in writing. If the consent cannot be obtained
in writing, the non-written consent must be formally documented and
witnessed.
23. When obtaining informed consent for the research project the

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physician should be particularly cautious if the subject is in a dependent
relationship with the physician or may consent under duress. In that case
the informed consent should be obtained by a well-informed physician
who is not engaged in the investigation and who is completely
independent of this relationship.
24. For a research subject who is legally incompetent, physically or
mentally incapable of giving consent or is a legally incompetent minor, the
investigator must obtain informed consent from the legally authorized
representative in accordance with applicable law. These groups should not
be included in research unless the research is necessary to promote the
health of the population represented and this research cannot instead be
performed on legally competent persons.
25. When subject deemed legally incompetent, such as a minor child, is
able to give assent to decisions about participation in research, the
investigator must obtain that assent in addition to the consent of the legally
authorized representative.
26. Research on individuals from whom it is not possible to obtain
consent, including proxy or advance consent, should be done only if the
physical/mental condition that prevents obtaining informed consent is a
necessary characteristic of the research population. The specific reasons
for involving research subjects with a condition that renders them unable
to give informed consent should be stated in the experimental protocol for
consideration and approval of the review committee. The protocol should
state that consent to remain in the research should be obtained as soon as
possible from the individual or a legally authorized surrogate.
27. Both authors and publishers have ethical obligations. In publication of
the results of research, the investigators are obliged to preserve the
accuracy of the results. Negative as well as positive results should be
published or otherwise publicly available. Sources of funding, institutional
affiliations and any possible conflicts of interest should be declared in the
publication. Reports of experimentation not in accordance with the

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principles laid down in this Declaration should not be accepted for
publication.
С. ADDITIONAL PRINCIPLES FOR MEDICAL RESEARCH
COMBINED WITH MEDICAL CARE
28. The physician may combine medical research with medical care, only
to the extent that the research is justified by its potential prophylactic,
diagnostic or therapeutic value. When medical research is combined with
medical care, additional standards apply to protect the patients who are
research subjects.
29. The benefits, risks, burdens and effectiveness of a new method should
be tested against those of the best current prophylactic, diagnostic, and
therapeutic methods. This does not exclude the use of placebo, or no
treatment, in studies where no proven prophylactic, diagnostic or
therapeutic method exists.
To further clarify the WMA position on the use of placebo controlled
trials, the WMA Council issued, during October 2001, a note of
clarification on article 29
30. At the conclusion of the study, every patient entered into the study
should be assured of access to the best proven prophylactic, diagnostic and
therapeutic methods identified by the study.
31. The physician should fully inform the patient which aspects of the care
are related to the research. The refusal of a patient to participate in a study
must never interfere with the patient-physician relationship.
32. In the treatment of a patient, where proven prophylactic, diagnostic
and therapeutic methods do not exist or have been ineffective, the
physician, with informed consent from the patient, must be free to use
unproven or new prophylactic, diagnostic and therapeutic measures, if in
the physician's judgement it offers hope of saving life, re-establishing
health or alleviating suffering. Where possible, these measures should be
made the object of research, designed to evaluate their safety and efficacy.
In all cases, new information should be recorded and, where appropriate,
published. The other relevant guidelines of this Declaration should be

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followed.
NOTE OF CLARIFICATION ON PARAGRAPH 29 of the WMA
DECLARATION OF HELSINKI
The WMA is concerned that paragraph 29 of the revised Declaration of
Helsinki (October 2000) has led to diverse interpretations and possible
confusion. It hereby reaffirms its position that extreme care must be taken
in making use of a placebo-controlled trial and that in general this
methodology should only be used in the absence of existing proven
therapy. However, a placebo-controlled trial may be ethically acceptable,
even if proven therapy is available, under the following circumstances:

- Where for compelling and scientifically sound methodological reasons

its use is necessary to determine the efficacy or safety of a prophylactic,
diagnostic or therapeutic method; or
- Where a prophylactic, diagnostic or therapeutic method is being
investigated for a minor condition and the patients who receive placebo
will not be subject to any additional risk of serious or irreversible harm.

All other provisions of the Declaration of Helsinki must be adhered to,

especially the need for appropriate ethical and scientific review.

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 CONTENTS

ETHICS. BIOETHICS …………………………………….…… 6

THE MAIN PRINCIPLES OF BIOETHICS …………………… 14
THE MAJOR RULES OF BIOMEDICAL PRACTICE ……….. 20
PHYSICIAN-PATIENT RELATIONSHIP ……………………. 28
ABORTION ……………………………………………………. 34
MODERN REPRODUCTIVE TECHNOLOGIES ………….…. 41
EUTHANASIA ………………………………………………... 48
SUICIDE …………………………………………………….….. 53
PALLIATIVE CARE …………………………………………… 61
HOSPICE ……………………………………………….……… 67
GENETICS AND ETHICS ………………………….………….. 71
THE PRINCIPLES OF ETHICS IN PSYCHIATRY …………. 76
AIDS: MORAL AND SOCIAL ASPECTS …………………….. 93
TRANSPLANTILOGY …………………………………….…. 105
GLOSSARY …………………………………………..……..... 112
QUESTIONS FOR SELF-CONTROL ………………………... 115
TESTS …………………………………………...……………. 117
BASIC RESOURCES IN BIOETHICS ………………………. 120
APPENDIX …………………………………………….…….... 124

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Лицензия ЛР № 020862 от 30.04.99 г.

Тираж 100 экз.

Отпечатано в типографии КГМУ.

305041, г. Курск, ул. К. Маркса, 3.

Заказ № 387

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