tag:blogger.com,1999:blog-33931205735547255282024-03-13T00:30:47.345+01:00EthoMedical Blog on Medical Ethics and Philosophy of MedicineUnknownnoreply@blogger.comBlogger6125tag:blogger.com,1999:blog-3393120573554725528.post-55505921455576607882014-06-02T14:21:00.002+02:002014-06-02T18:09:58.348+02:00On a Cosmopolitan Definition of Death<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg8yF-Ro6d-oW8v66Nlt7-_CtheEgpWV91foBBurBRbFhYrdp1BIGHlw7VtrGfyZtKFezw2U3em3UTU4JraL6wfVHteiLl_PpJQObESV4mtfVWWAHMjnJsIG5f7MiZpIzwAvy5vOxkhHCI/s1600/the_death_of_socrates.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg8yF-Ro6d-oW8v66Nlt7-_CtheEgpWV91foBBurBRbFhYrdp1BIGHlw7VtrGfyZtKFezw2U3em3UTU4JraL6wfVHteiLl_PpJQObESV4mtfVWWAHMjnJsIG5f7MiZpIzwAvy5vOxkhHCI/s1600/the_death_of_socrates.jpg" height="214" width="320" /></a></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-ansi-language: EN-US;">Most traditional mythologies have equated life to
breath. Breath was considered to be something more than respiration, linked -in a
tradition that goes back to myths of Anima Mundi- to some sort of universal
life. In this context, death was the departure of such transcendental airy
entity towards fabulous scenarios of different kinds. The link of breathing and
the capacity for speech contributed for a further metaphysical development of
the physiological act of oxygenation. The Parmenidean tradition in Greece, but
especially the Aristotelian philosophy, linked life more to intelligence than
to any other physiological action. In fact, in the Metaphysics, Aristotle
declares life to be some sort of intelligence. This double link, to breathe and
to intelligence, in their transcendental or materialistic interpretations, gave
for centuries a cornerstone for the definitions of life. Even, in the practice
of modern medicine up to the 1960’s, it was the loss of the capacity to breathe
(together with the loss of blood flow) the key property for the definition of
death. The definition of death elaborated by the Academy of Medical Royal
Colleges in 2008, declares death as the irreversible loss of the capacity for
consciousness, combined with irreversible loss of the capacity to breathe.
Here, the concept <i>consciousness</i>
merely describes a physiological process that would be better described as <i>a state of vigilance</i>, opposed to sleep,
coma or anesthesia, but in any case, implies the expression of intelligence in
its more basic terms. Thus, according to this definition death is a combination
of an irreversible loss of any state (process) of vigilance and the capacity to
breathe.<o:p></o:p></span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-ansi-language: EN-US;">Irreversibility of functional performance seems at
first a good indicator for death, especially irreversible loss of critical
systems which lead to a general collapse of the body, like it used to be the
loss of capacity to breathe or to pump blood. However, the invention of
mechanical ventilators during the 1960’s changed the conceptual scene and
patients with massive brain destruction could maintain with the help of
machines a relatively healthy functioning of other systems. David Cole has
convincingly argued that <i>irreversibility</i>
is not an absolute concept in relation to the medical definition of death, for
it is conditioned both by the state of the medical technology and by the
scenarios where the death situation may occur (it is not the same a massive
heart attack in a hospital that in a camping in the mountains). If we consider
the changes in medical science, we may induce that what today is not
irreversible may be reversed tomorrow, so it seems futile to try to give final
definitions and limits for such a dynamical field of knowledge in which
biomachines may alter radically the way we look today to the functioning of
human organs. <o:p></o:p></span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-ansi-language: EN-US;">All that is needed is a working definition which can
be used in the context of the main legal and ethical frames (Human Rights Declaration,
etc.) to avoid abuses and violations of human rights. The common ground for
ethics and medicine is not the performance of a particular organ or a system of
them, but the social persona. Therefore, irreversibility has to be measured in
relation to that persona, and in many cases it means that there are
irreversible loses even in situations when no major organs have been affected
but a general impairment ends with the life of the patient as s/he knew it. This
problem would need to be addressed and complemented in relation to the questions of assisted
suicide and the property which the individual has over his or her body. Since
human beings are symbolical, the symbolical emergent dimension has to be added
to the physiological one. The symbolical approach can be so different as the
materialistic one of physiology in relation to the transcendental one which
speaks about resurrections. In fact, the discrepancies affect to the social
persona, for while science speaks of the persona in terms of the political
legal system in which it is developed, religion speaks of a transcendental
persona beyond the political one. How to harmonize such a complex symbolical
scenario? One possible solution is a plain appeal to consistency of action:
medicine treats the socio-political persona according to the general legal
frames, while leaves the metaphysical person as a private question of the
patient. But this implies that religion also does not interfere with the
clinical practice (beyond its conditionings in the general beliefs which are
gathered in the ethical codes of the group). <b>A person would be clinically dead when its body functions where so
impaired as to impede any psycho-social communication</b>. Such an assessment
needs a careful and thorough examination of each individual case and has to be
independent of considerations in relation to organ donation, unless previously
specified by the patient in actual statements and reports. We would need
databases with patient decisions in relation to different health scenarios
which could affect them.<o:p></o:p></span></div>
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<u><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-US;">Some References<o:p></o:p></span></u></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-ansi-language: EN-US;">Academy of Medical Royal Colleges [2008] <i>A Code of Practice for the Diagnosis and
Confirmation of Death.</i>
http://www.aomrc.org.uk/doc_view/42-a-code-of-practice-for-the-diagnosis-and-confirmation-of-death.<o:p></o:p></span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-ansi-language: EN-US;">Bosnell, Rose and Madder, Hilary.[2011] <i>Concepts of brain death</i>.<u> </u></span><span style="font-family: "Times New Roman","serif"; font-size: 12pt;"><a href="http://www.sciencedirect.com/science/journal/02639319" title="Go to Surgery (Oxford) on ScienceDirect"><span lang="EN-US" style="border: 1pt none windowtext; color: windowtext; padding: 0cm;">Surgery (Oxford)</span></a></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12pt;">. </span><span style="font-family: "Times New Roman","serif"; font-size: 12pt;"><a href="http://www.sciencedirect.com/science/journal/02639319/29/7" title="Go to table of contents for this volume/issue"><span lang="EN-US" style="border: 1pt none windowtext; color: windowtext; padding: 0cm;">Volume 29, Issue 7</span></a></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-ansi-language: EN-US; mso-fareast-font-family: "Arial Unicode MS";">, July
2011, Pages 289–294.<o:p></o:p></span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-ansi-language: EN-US;">Cole, D. J. (1993), Statutory Definitions of Death and the Management of
Terminally<o:p></o:p></span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-ansi-language: EN-US;">Ill Patients Who May Become Organ Donors After Death, </span><i><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-ansi-language: EN-US; mso-fareast-font-family: Minion-Italic;">Kennedy
Institute of Ethics<o:p></o:p></span></i></div>
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<i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: Minion-Italic;">Journal</span></i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">, 3: 145–55.</span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-US;">Youngner, Stuart
J. <i>The Definition of Death</i>. [2007] In The <i>Oxford Handbook of Bioethics</i>. p.p.
285-303. Oxford University Press. 2007.<o:p></o:p></span></div>
Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3393120573554725528.post-12575625729482221482014-05-08T12:49:00.000+02:002014-05-08T13:03:38.115+02:00The five normative postulates of Evidence Based Medicine<div class="MsoNormal" style="line-height: 150%; text-indent: 14.2pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: EN-US;">Evidence Based Medicine (EBM) is rooted in five linked
<i>ideas</i> [Davidoff, Haynes, Sackett & Smith, 1995]:<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman";">1.<span style="font-family: 'Times New Roman'; font-size: 7pt; line-height: normal;">
</span></span><!--[endif]--><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: EN-US;">Clinical
decisions should be based on the best available scientific evidence. <o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman";">2.<span style="font-family: 'Times New Roman'; font-size: 7pt; line-height: normal;">
</span></span><!--[endif]--><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: EN-US;">The
clinical problem-rather than habits or protocols-should determine the type of
evidence to be sought. <o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman";">3.<span style="font-family: 'Times New Roman'; font-size: 7pt; line-height: normal;">
</span></span><!--[endif]--><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: EN-US;">Identifying
the best evidence means using epidemiological and biostatistical ways of
thinking.<o:p></o:p></span></div>
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<!--[if !supportLists]--><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman";">4.<span style="font-family: 'Times New Roman'; font-size: 7pt; line-height: normal;">
</span></span><!--[endif]--><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: EN-US;"> Conclusions derived from identifying and
critically appraising evidence are useful only if put into action in managing
patients or making health care decisions.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; mso-list: l0 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman";">5.<span style="font-family: 'Times New Roman'; font-size: 7pt; line-height: normal;">
</span></span><!--[endif]--><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: EN-US;">Performance
should be constantly evaluated.<o:p></o:p></span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: EN-US;">The five normative postulates express a program for medical practice
which has been widely and enthusiastically accepted by the medical community.<o:p></o:p></span><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhAFinUUmQr-puPaPPE-wT66n-U-h1AMJecTjp4HO-hoJY2_1VQQsqIt9g71bmYeIY9KRUAKPAVKxkrcb63OYHwf64tK_4dZXkd2lqapA91FM1-r8soKHGlzIW0YTJ8MK8fv087KlclpqQ/s1600/Van+der+Meer.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhAFinUUmQr-puPaPPE-wT66n-U-h1AMJecTjp4HO-hoJY2_1VQQsqIt9g71bmYeIY9KRUAKPAVKxkrcb63OYHwf64tK_4dZXkd2lqapA91FM1-r8soKHGlzIW0YTJ8MK8fv087KlclpqQ/s1600/Van+der+Meer.jpg" height="148" width="200" /></a></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: EN-US;">Postulate one is a call for continuous formation on
the part of the physician, the acknowledgement of the rapid and continuous
development of life sciences and the imperative need for theoretical and
practical updates in the fields of those sciences: medical education is an
ongoing process. One major problem with this sound proposal is the availability
and transparency of scientific information: human health is an industry and
information is restricted by market conditions. Besides this social objection
to the implementation of the postulate, we meet an epistemological one: the
concept of <i>medical evidence</i> is
problematic. The problem is subsumed
under the belief in the unquestionable validity of the randomized controlled
trials, but the statistical efficacy of a treatment, per se, is not sufficient
for its implementation: statistical evidence needs also theoretical integration,
i.e., has to be understood in a wider reference frame if we want to have some
control over possible <i>perverse effects</i>
(using Merton’s trerminology) unforeseen in statistical conceptual frames. In
the health sciences, it is now a commonplace that both mechanistic and
probabilistic evidence are required to substantiate causal claims [Russo and
Williamson, 2007]. The history of medicine presents many cases in which causal
claims made solely on the basis of statistics have been rejected until backed
by mechanistic or theoretical knowledge [Russo and Williamson, 2007].<o:p></o:p></span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: EN-US;">Postulate two expands what was said in postulate one,
it is basically a call against inertia and mechanic medical action. Its
implementation encounters several economic problems.<o:p></o:p></span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: EN-US;">Postulate three is an epistemological declaration: the
medical method should be mainly statistical. As we just said, biostatistics by
itself is not enough for medical practice: without a theoretical frame,
statistics is nothing but uninterpreted data. On the other hand, the
implementation of a health program not fully understood is a plea for what the
social sciences call <i>perverse effects</i>.<o:p></o:p></span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: EN-US;">Postulate four is an ethical demand for the EBM
program: the purpose of the medical practice is to cure patients. In this
sense, is not a dehumanized practice as its opponents advocate. On the other
hand, we could not say that EBM expresses a humanistic approach, for it has not
an anthropological perspective upon the medical practice as a social action.<o:p></o:p></span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: EN-US;">Finally, postulate five extends the ideas expressed in
P1 and P2.<o:p></o:p></span></div>
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<u><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: EN-US;">References<o:p></o:p></span></u></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: EN-US;">Davidoff, F., Haynes, B., Sackett, D., and Smith, R. <i>Evidence-based medicine</i>. [1995]. British
Medical Journal, 310, 1085–1086. <o:p></o:p></span></div>
<br />
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: EN-US; mso-bidi-font-style: italic;">Russo, Federica, and
Williamson, Jon. <i>Interpreting
Causality in the Health Sciences</i>. [2007] International Studies in the
Philosophy of Science. Vol. 21, No. 2, July 2007, pp. 157–170.<o:p></o:p></span></div>
Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3393120573554725528.post-58946468151488358652014-05-01T19:32:00.001+02:002014-05-01T20:13:39.586+02:00EthoMedical Leaves: Treatment choices when the patient is incapacitated<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi4ao-_78HxxTld350QRxoZqRZxT7JRwXOojmoPPyAYvBvW435-qG3G1hmkmfbEKTlmmsM3Lix_iIcbCSeRBzwXbNAxseHy81_U3aXYwnWlFH73UXdQfow7Y7wd6avSARUQM3657hGfgIg/s1600/Leaves.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi4ao-_78HxxTld350QRxoZqRZxT7JRwXOojmoPPyAYvBvW435-qG3G1hmkmfbEKTlmmsM3Lix_iIcbCSeRBzwXbNAxseHy81_U3aXYwnWlFH73UXdQfow7Y7wd6avSARUQM3657hGfgIg/s1600/Leaves.jpg" height="240" width="320" /></a></div>
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<span style="color: #0b5394;"><b>David Wendler and <a href="http://annals.org/article.aspx?articleid=746856">Annete Rid</a></b>’s</span> [2011]study on surrogates treatment decisions has shown that at least one third of the surrogates experienced a negative emotional burden as the result of making the choice. Rid, Wendler and others have proposed the use of a Patient Preference Predictor (PPP) -an actuarial model for prediction- that gathers particular information about the treatment preferences of a population sample and produces the treatment option that an individual patient would be most likely to prefer.</div>
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<span lang="EN-US"><br /></span>
<span lang="EN-US"><b>One question</b>: </span>What about
asking patients about their own choices for most common scenarios and preparing
files well in advance, when signing health insurance policies? The collected database would certainly improve the actuarial model of prediction for all those cases where there is not an opportunity to ask the patient.</div>
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<u>References</u></div>
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<span style="font-size: small;"><span id="ctl00_scm6MainContent_lblArticleTitle" style="border: 0px; font-family: inherit; font-style: inherit; font-variant: inherit; font-weight: inherit; line-height: inherit; margin: 0px; padding: 0px; vertical-align: baseline;"><span style="background-color: white; font-family: Helvetica, Arial, Verdana, sans-serif; line-height: 17.998498916625977px;">Wendler, David and Rid, </span></span><span style="background-color: white; font-family: Helvetica, Arial, Verdana, sans-serif; font-style: inherit; font-variant: inherit; font-weight: inherit; line-height: 17.998498916625977px;">Annette.</span><span style="background-color: white; font-family: Helvetica, Arial, Verdana, sans-serif; font-style: inherit; font-variant: inherit; font-weight: inherit; line-height: 17.998498916625977px;"> </span><span style="font-family: inherit; font-variant: inherit; font-weight: inherit;"><i>The Effect on Surrogates of Making Treatment Decisions for Others</i></span><span style="font-family: inherit; font-style: inherit; font-variant: inherit; font-weight: inherit;">. [2011]. </span><em style="background-color: white; border: 0px; font-family: Helvetica, Arial, Verdana, sans-serif; line-height: 17.998498916625977px; margin: 0px; padding: 0px; vertical-align: baseline;">Ann Intern Med. </em><span style="background-color: white; font-family: Helvetica, Arial, Verdana, sans-serif; line-height: 17.998498916625977px;">2011;154(5):336-346.</span></span></h1>
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<span lang="EN-US"><o:p></o:p></span></div>
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Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3393120573554725528.post-24392401638347653542014-04-28T14:17:00.001+02:002014-05-29T21:10:21.684+02:00Feeding the gods: the market of human organs<div align="center" class="MsoNormal" style="text-align: center;">
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhhmBI-8uK57Xb50BwbDK0Aty2HOKtysnfaNp-NOSbv-fSeydDrLbwU3dI3lnKSNgUBRTXCwpuYEfGwAbZqD-w-2PYKRc56acruXyOQ5rLFSmgZMK7R-BL4KdwDVTGzDMD_fjWEEP9DieM/s1600/Francisco_de_Goya,_Saturno_devorando_a_su_hijo_(1819-1823).jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhhmBI-8uK57Xb50BwbDK0Aty2HOKtysnfaNp-NOSbv-fSeydDrLbwU3dI3lnKSNgUBRTXCwpuYEfGwAbZqD-w-2PYKRc56acruXyOQ5rLFSmgZMK7R-BL4KdwDVTGzDMD_fjWEEP9DieM/s1600/Francisco_de_Goya,_Saturno_devorando_a_su_hijo_(1819-1823).jpg" height="400" width="217" /></a></div>
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: EN-US;">In the Samoan myths of the afterlife, the soul of the poor is food for
the soul of the noble and rich [Frazer, 1922]. Are we living in the Samoan
afterlife? Well, for some of our unfortunate contemporaries the situation is
not so different. Simon Rippon has discussed the issue in an interesting paper
on the Journal of Medical Ethics, where he analyzes the thesis of the moral and
economic benefits for the poor which provides the free market of live donor organs.
He expresses the thesis of the Laissez-Choisir
(LC) argument in three premises.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%; mso-layout-grid-align: none; text-autospace: none;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: EN-US;">P1. People in poverty
who would choose to sell their organs if a free market existed must regard all other
options open to them as worse.<o:p></o:p></span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: EN-US;">P2. If we take
away what some regard as their best option, we thereby make them worse off, at
least from their own perspective.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%; mso-layout-grid-align: none; text-autospace: none;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: EN-US;">P3. If a policy makes
some worse off from their own perspective, it would be paternalistic for us to judge
otherwise and to implement the policy on their behalf. We ought not to be
paternalistic in this way. Therefore, we ought not to prohibit organ markets for
the supposed good of those in poverty who would choose to sell their organs if
a free market existed. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%; mso-layout-grid-align: none; text-autospace: none;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: EN-US;">LC has been
subscribed by Julian Savulescu [2003] and by Gerald Dworkin [1994] on the
grounds of the freedom of choice of the sellers and the paternalism of any
attempt to regulate the market. Janet Radcliffe Richards [Radcliffe et al.,1998],
on the other hand, has subscribed LC on the grounds of a worse scenario if the
prohibition is reinforced. Rippon’s paper refutes LC's claims on the grounds that sometimes
you may hurt people by giving them an option that they would be better off
taking: the addition of the option makes it
more difficult or costly to perform the reasoning necessary to reach the best
decision. His argumentation refutes P2, but fails to address what from my point
of view is at the center of this moral problem: hypocrisy, or put in ethical
terms, the inconsistency between the moral values of society and its actions.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%; mso-layout-grid-align: none; text-autospace: none;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: EN-US;">The appeals to
freedom of choice are a mockery: freedom of choice is always limited by initial
conditions and only possible in a system with perfect flow of information, i.e.,
is just an ideal condition, a convenient narrative of domination which
justifies many abuses. The sellers of organs do not know the full scenario but
simply get into further trouble, buying themselves, at best, some extra-time: we are offering to the person a floating device so s/he
can be saved to be properly eaten lately by the sharks. When we appeal for the
freedom to decide upon our own body, we forget that such a right is denied at
large throughout the world, as we see in the relation to the free use of drugs,
or in war situations, or in terminal diseases: the restrictions on the freedom
of choice for the individual in these three scenarios is inconsistent with the
approval of a free live donor market. We have to decide, the body belongs to
the individual or it does not. But even if we reach the civilized point of
letting the individual decide upon his (her) life and body, the idea of a free
market does not necessarily follows. Why should there be market conditions for
human transplanting? The still on-going belief on the supernatural capacities
of the invisible hand of the market, the old Laissez Faire, is an old
superstition linked to other supernatural beliefs and has no grounds on
economic data: market crisis are paid by the population at large through public
funds. <o:p></o:p></span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: EN-US;">There are not easy and straightforward rational solutions when
ontologies are involved, especially when those are <i>otherworld</i> valuations. The live donor market problem has,
nonetheless a solution based on human valuations. If we value life and freedom
of choice we cannot interfere in the free donation of organs, but it seems
rather perverse and human degrading the idea of solving (or even alleviating)
poverty through merchandizing human body parts. Although prostitution reaches
beyond the sex domain into realms of manipulation and domination, when we are
dealing with body parts, nobody would sell a part of his/her body if the need
for survival was not urgent. The control of the organ market by society will
force other solutions for poverty, more permanent and consistent with the
values that we are teaching to our children and write in our Constitutions, the values that can hold a
community as a human social contract. From my point of view, our own life
cannot be maintained at any price. We have reached to this point of social evolution
precisely by standing against barbarisms and abuses. The ridicule and shallow
proposals for a human life based only on money valuations, are an insult against
intelligence, and therefore, against life.<o:p></o:p></span></div>
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<u><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: EN-US;">References<o:p></o:p></span></u></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-autospace: none;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: EN-US;">Dworkin G. [1994]<i>Markets
and Morals</i>. In: Dworkin G, ed. <i>Morality,
Harm and the Law</i>.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: EN-US;">Oxford: Westview. 1994. 155–61.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: EN-US;">Frazer, James. [1922]. <i>The Belief in Immortality and the Worship of
the Dead. Vol. 2. </i> MacMillan and Co.,
London.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-autospace: none;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: EN-US;">Radcliffe Richards J, Daar A, Guttmann R, et al. [1998]
<i>The case for allowing kidney sales</i>. Lancet.
1998. 351:1950–2.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0cm;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Rippon,
Simon. </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-US;">[2012] <i>Imposing options on people in poverty: the
harm of a live donor organ market.</i> JME. </span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Med Ethics 2014;40:145–150.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: EN-US;">Savulescu J.[2003] <i>Is the sale of body parts wrong?</i> JME
2003;29:138–9.<o:p></o:p></span></div>
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Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3393120573554725528.post-21426998652401157622014-04-13T20:28:00.001+02:002014-05-01T20:01:45.285+02:00What is the purpose of prolonging life in painful terminal diseases?<div class="MsoNormal">
<span lang="EN-US">Let us
examine the problem from the point of view of a rational ethics based on
anthropological grounds. By <i>rational</i>,
I mean a discourse whose statements are not contradictory among themselves, and
by <i>anthropological grounds</i> I mean a
non-transcendental valuation of life, a human axiology. Particularly, I will
use two anthropological ethic principles:<o:p></o:p></span></div>
<div class="MsoNormal">
<span lang="EN-US">P.1 <u>Principle
of life preservation</u>: We have to preserve human life.<o:p></o:p></span></div>
<div class="MsoNormal">
<span lang="EN-US">P.2 <u>Principle
of primacy of the public interest</u>: the life of the group has preference
over the life of the individual. Human individual life is conditioned by the
life of the group and subsumed to its needs. Not only my actions are rightful
when they do not imply any sort of harm to others, but they cannot be
autonomous when there is an urgent need of society: we work and die for the
group whenever is needed. And since the needs of society are always urgent,
life preservation is limited by public interest, as has always been the case
with wars.<o:p></o:p></span><br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjTueHNXJkGwY9NGZzRtpB7tZidDE8OxJhgtgwiHYvmRARGY1oeuuNHFbRPck3bzXka5xjYgtcsJnANv0j3k0Z-4wuPHcio0KCud6Y5GuhzR9wm-gQHGxyTAFDMCt3uUWXemULpKHl2Bpk/s1600/Deat+of+Hercules+Deshays+1762.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjTueHNXJkGwY9NGZzRtpB7tZidDE8OxJhgtgwiHYvmRARGY1oeuuNHFbRPck3bzXka5xjYgtcsJnANv0j3k0Z-4wuPHcio0KCud6Y5GuhzR9wm-gQHGxyTAFDMCt3uUWXemULpKHl2Bpk/s1600/Deat+of+Hercules+Deshays+1762.jpg" height="320" width="262" /></a></div>
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US">In relation
to our question, we can imagine, at least, the following scenarios for a dying
patient in pain:<o:p></o:p></span><br />
<span lang="EN-US"><br /></span></div>
<div class="MsoListParagraphCxSpFirst" style="mso-list: l1 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span lang="EN-US">1 </span><u><span lang="EN-US">The patient is sustained by public
funds</span></u><span lang="EN-US">.</span><span lang="EN-US" style="text-indent: -18pt;"><span style="font-size: 7pt;"> </span></span></div>
<div class="MsoListParagraphCxSpFirst" style="mso-list: l1 level1 lfo1; text-indent: -18.0pt;">
<span style="text-indent: -18pt;"><span style="font-size: 9.333333015441895px;"> </span> a. Society denies further sustenance
for it is an incurable disease and cannot benefit from the situation.</span><span lang="EN-US" style="text-indent: -18pt;"><span style="font-size: 7pt;"> </span></span><br />
<span lang="EN-US" style="text-indent: -18pt;"><span style="font-family: Arial, Helvetica, sans-serif;"> b.</span><span style="font-size: 7pt;"> </span></span><span lang="EN-US" style="text-indent: -18pt;">Society agrees to sustain the
patient despite the non-economic benefits of the situation.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 54.0pt; mso-add-space: auto; mso-list: l4 level1 lfo3; text-indent: -18.0pt;">
<!--[if !supportLists]--><span lang="EN-US">1.<span style="font-size: 7pt;"> </span></span><!--[endif]--><span lang="EN-US">The community wants the person to
live longer in pain.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 54.0pt; mso-add-space: auto; mso-list: l4 level1 lfo3; text-indent: -18.0pt;">
<!--[if !supportLists]--><span lang="EN-US">2.<span style="font-size: 7pt;"> </span></span><!--[endif]--><span lang="EN-US">The community wants the person to
live longer but not in pain.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 54.0pt; mso-add-space: auto; mso-list: l4 level1 lfo3; text-indent: -18.0pt;">
<!--[if !supportLists]--><span lang="EN-US">3.<span style="font-size: 7pt;"> </span></span><span lang="EN-US">The community leaves the choice to
the individual.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l1 level1 lfo1; text-indent: -18.0pt;">
<!--[if !supportLists]--><span lang="EN-US">2<span style="font-size: 7pt;"> </span> </span><!--[endif]--><u><span lang="EN-US">The patient is self-sustained</span></u><span lang="EN-US">.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 40.8pt; mso-add-space: auto; mso-list: l3 level1 lfo4; text-indent: -18.0pt;">
<!--[if !supportLists]--><span lang="EN-US">a.<span style="font-size: 7pt;"> </span></span><span lang="EN-US">Still the society wants to exercise
the control.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 58.8pt; mso-add-space: auto; mso-list: l2 level1 lfo5; text-indent: -18.0pt;">
<!--[if !supportLists]--><span lang="EN-US">1.<span style="font-size: 7pt;"> </span></span><!--[endif]--><span lang="EN-US">Society wants the individual to
suffer.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 58.8pt; mso-add-space: auto; mso-list: l2 level1 lfo5; text-indent: -18.0pt;">
<!--[if !supportLists]--><span lang="EN-US">2.<span style="font-size: 7pt;"> </span></span><!--[endif]--><span lang="EN-US">Society wants the individual to live
longer but not to suffer.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: 40.8pt; mso-add-space: auto; mso-list: l3 level1 lfo4; text-indent: -18.0pt;">
<!--[if !supportLists]--><span lang="EN-US">b.<span style="font-size: 7pt;"> </span>S</span><span lang="EN-US">ociety declares the case to be
a private choice.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: 40.8pt; mso-add-space: auto; mso-list: l3 level1 lfo4; text-indent: -18.0pt;">
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US">In the case
1.a, when the patient is sustained by private funds and society denies further
sustenance, we are dealing with a rational choice according to principles 1 and
2, for P1 cannot be enacted (is a terminal disease), and there is nothing
positive for the patient (supposing that s/he is driven by the principle of
avoiding pain) in the situation. The rational action is assisted death.<o:p></o:p></span><br />
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US">The second
choice has, in turn, three scenarios. The first one, 1.b.1 is not as rare as it
would seem. Such is the case with criminals or by religious motives in which
the valuation of pain extends beyond this life to other worlds. There are
religious ethical values which consider suffering as a way for purgation in a
context of otherworld scenarios. Here, is not the principle of life
preservation what is at work, but a principle of punishments and rewards on a
transmundane scale, which is contrary both to any anthropological principles
and to the structure of most of our legal systems. Since this punishment does
not serve any practical purpose for the community, beyond sadistic morbid
satisfactions, it obeys only non-rational valuations, therefore are not part of
a rational ethics. <o:p></o:p></span><br />
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US">The second
scenario of the second choice, 1.b.2, when the community wants the person to
live his/her final days without pain, does not affect the principle of life
preservation, for life cannot be preserved in this case, and also conforms to
the public interest principle, which in this case is to alleviate the patient’s
pain. The rational action is the alleviation of pain whether by the increase of
medication for relieve, or by the shortening of the condition of pain. If pain
cannot be alleviated, the rational outcome of the scenario is assisted death,
for since P1 cannot be accomplished and the choice is not to suffer, it can
only be obtained by shortening the duration of pain.<o:p></o:p></span><br />
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US">The third
scenario, 1.b.3, is to leave the choice to the patient, which will decide
therefore either to continue his/her suffering to the very end or to suicide.
None of these decisions is contrary to the ethical principle of life
preservation nor to the one of public interest, for life cannot be prolonged
and the community has passes the choice to the patient, i.e., has given the
ownership of life to the individual. This case is equivalent to 2.b, and both
are rational actions.<o:p></o:p></span><br />
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US">The case
2.a. 1, when the patient is self-sustained and society still wants to control the
life of the individual for it wants him to suffer (for whatever ethical or
metaphysical reasons) is equivalent to the 1.b.1, and therefore, is not a
choice of rational ethics. On the other hand, the case 2.a.2, is analogous to
1.b.2, and represents a choice of rational ethics which developed to its
consequences leads to assisted death.<o:p></o:p></span></div>
<br />
<div class="MsoNormal">
<span lang="EN-US">Therefore,
pain can only be prolonged in terminal disease cases under non-rational ethical
principles, whether those corresponding to the personal choice of the individual
or the group.<o:p></o:p></span></div>
Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3393120573554725528.post-89691405007151835472014-04-02T14:33:00.000+02:002014-04-02T19:51:05.035+02:00Medical Ethics<div align="center" class="MsoNormal" style="text-align: center;">
<div class="MsoNormal" style="text-align: center;">
<br /></div>
<div class="MsoNormal" style="text-align: center;">
<br /></div>
<div class="MsoNormal" style="text-align: justify; text-indent: 14.2pt;">
<span lang="EN-US" style="font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-US;">The
prevention and treatment of illnesses is conditioned not only by our biological
knowledge but also by the effective integration that we have of other sciences
and our control of the physical environment. Medicine is obviously linked to
the rest of human knowledge but, being the science of human life, is also determined
by the particular social forms in which our life develops, by the economical
conditionings in which health and sickness find an additional restriction. In
this sense, medicine is a social science and a social action, not a mere
biological knowledge of the physiological functions of the human body.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-align: justify; text-indent: 14.2pt;">
<span lang="EN-US" style="font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-US;">The social
action of medicine, the self-care and self-preservation performed by human
societies, is not the result of the efforts and ideas of a single generation
but a vast cultural endeavor. For that reason, it cannot come as a surprise
that beyond the evident success of our survival as species, the accomplishments
and failures of the medical practice have not been measured with an identical
rod, and the very same biological actions of life and death have been ethically
valuated differently according to diverse axiological systems. Medical actions
have not a simple biological valuation but a symbolically complexified domain
which gives them a particular axiological tension. Such encounter of disparate
forces –common to other life sciences- demands from medicine a continuous
critical thinking in which theoretical reflections cannot lose sight of its
everyday praxis, the resolution –urgent most of the times- of cases in which a
concrete human being fights with death in unbearable pain. Medical ethics is
the result of this critical thinking, covering a wide domain of problems, from
the moral decisions of the clinical practice to the questioning of concepts
like <i>health</i>, <i>sickness</i>, <i>person</i>, <i>life</i> and <i>death</i>, providing philosophical frames for their definitions. On the
other hand, medical ethics examines critically the cutting edge research of the
biological sciences, taking care that the main international political and
ethical agreements are honored, and that the human being is treated within the
ideals of respect, equality and dignity.<o:p></o:p></span></div>
<div class="MsoNormal" style="text-align: justify; text-indent: 14.2pt;">
<span lang="EN-US" style="font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-US;">Medical
ethics, like any other ethical action, is a ground for continuous disagreements
and conflict at the individual and collective level. The differences of ethical
codes are founded on different metaphysical values linked to ways of life,
leaving little room for philosophical argumentation. Today, human ethical
valuations range from those of the <i>Anima
Mundi</i> groups and nations, to mixtures of different kind of universalisms of
the laws and gods, passing through the materialistic valuations of modern
science. In this global milieu, if there is going to be any general reference frame
for ethics it has to be the consensual international conventions and
declarations where the social person of the human being is put, at least
ideally, at the center of any medical action. The<a href="http://www.un.org/en/documents/udhr/"> </a></span><span lang="EN-US" style="font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-US;"><a href="http://www.un.org/en/documents/udhr/">Universal Declaration of Human Rights</a></span><span lang="EN-US" style="font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-US;"> proclaimed by the General
Assembly of the United Nations on 10 December 1948, the </span><span lang="EN-US" style="font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-US;"><a href="http://conventions.coe.int/Treaty/en/Treaties/Html/005.htm">Conventionfor the Protection of Human Rights and Fundamental Freedoms</a></span><span lang="EN-US" style="font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-US;"> of
4 November 1950, the </span><span lang="EN-US" style="font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-US;"><a href="http://www.icrc.org/ihl/INTRO/540?OpenDocument">Conventionon the Rights of the Child</a></span><span lang="EN-US" style="font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-US;"> of 20 November 1989, are today
the pillars for any medical ethics, not as a final charts, but as starting
points for further development.<o:p></o:p></span></div>
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<span lang="EN-US" style="font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-US;">When we talk
about medical ethics we are therefore talking about a praxiological action
(ethical and political) with epistemological consequences. The definitions of <i>life</i>, <i>death, person, human being, sickness, health, pain, individual
consciousness</i>, etc., -according to our present knowledge of the universe-
determine intellectual frames of reference that will produce new emotional and
cognitive horizons. Such an expansion is not ethically easy. Medical ethics
needs to be expressed through non-contradictory critical argumentations and not
simply by sterile appeals to religious or political authority. To this methodological
axiom, I would add the inspiring role of two ethical values which underlie not
only the Hippocratic Oath, but also Aristotle’s works on ethics: love for life and
valor. <o:p></o:p></span></div>
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