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Abstract
The increasingly used concept new public health indicates that a fundamental change has occurred in the goals and methods of disease prevention and health promotion. The change is often said to imply less expert-driven governing of citizens. In this article, governing technologies in the field of public health in Denmark and Sweden are analysed to investigate whether substantial changes have taken place in the governing efforts. In the endeavours unfolded in relation to health examinations for children and pregnant women during the last eighty years, no apparent evidence exists of a significant change in governing technologies. Regulatory, expert-driven and empowering technologies have been used during the whole period; additionally, appeals to autonomy, responsibility and obedience as well as to trust in authorities co-exist throughout the period. The fundamental change is the huge increase in the health authorities' governing ambitions.
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Affiliation(s)
- Signild Vallgårda
- Signild Vallgårda, Professor, Unit of Health Services Research, Department of Public Health, University of Copenhagen , Øster Farimagsgade 5, 1014 Copenhagen K, Denmark ; E-mail:
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2
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Cassels A. World's first nonprofit drug company launched. CMAJ 2003; 169:590. [PMID: 12975232 PMCID: PMC191304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023] Open
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3
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Cassell EJ. The principles of the Belmont report revisited. How have respect for persons, beneficence, and justice been applied to clinical medicine? Hastings Cent Rep 2000; 30:12-21. [PMID: 10971887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
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4
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Tanner DE. Narrative, ethics, and human experimentation in Richard Selzer's "Alexis St. Martin": the miraculous wound re-examined. HEC Forum 2000; 12:149-60. [PMID: 11066194 DOI: 10.1023/a:1008949000333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- D E Tanner
- Massachusetts College of Pharmacy and Health Sciences, Boston 02115, USA
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5
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6
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Abstract
Recently there has been a revival of interest in the theory and practice of eugenics by both academics and lay people. The ongoing revolution in biology and the increasing ability to acquire genetic information has led to concerns about genetics being used again for sinister eugenic ends. Although the goals behind traditional eugenics--the minimization of disease and the improvement of human health--remain unchanged, the means by which these goals should be achieved have altered significantly. However, in debates about the impact of human genetic research, eugenics is sometimes viewed as a purely historical phenomenon and its relevance to the current situation is minimized. This article outlines the history of the eugenics movement, describes some eugenic practices, and explores why an appreciation of these historical debates is important for nurses.
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Affiliation(s)
- R Iredale
- Nursing and Midwifery Research Unit, School of Care Sciences, University of Glamorgan, Pontypridd, UK
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7
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Abstract
Fifty years ago, 23 Nazi physicians were defendants
before a military tribunal in Nuremberg, charged with crimes
against humanity. During that trial, the world learned
of their personal roles in human experimentation with political
and military prisoners, mass eugenic sterilizations, state-ordered
euthanasia of the “unfit,” and the program
of genocide we now know as the Holocaust. These physicians,
and their colleagues who did not stand trial, were universally
condemned in the free world as ethical pariahs. The term
“Nazi doctor” became the paradigm for total
defection from the most rudimentary elements of medical
morality. The caduceus literally became the instrument
of the swastika.
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Affiliation(s)
- E D Pellegrino
- Center for Clinical Bioethics, Georgetown University Medical Center, Washington, D.C., USA
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8
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10
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11
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12
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13
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Abstract
In the United States and Germany before World War II, physicians participated in state-authorized eugenic sterilization programs in an attempt to prevent persons deemed to possess undesirable heritable characteristics from propagating. A comparison of U.S. and German histories reveals similarities that argue against easy dismissal of a Nazi analogy. On the basis of a review of editorials in New England Journal of Medicine and Journal of the American Medical Association from 1930 to 1945 it is difficult to accept the suggestion that the alliance between the medical profession and the eugenics movement in the United States was short-lived. Comparison of the histories of the eugenic sterilization campaigns in the United States and Nazi Germany reveals important similarities of motivation, intent, and strategy and differences that explain why support for eugenic sterilization in the United States gradually weakened. The eugenics movement in Germany was influenced by economic crisis, radical nationalism, Hitler's totalitarianism, and the medical profession's willing participation and attraction to Nazism for financial and ideological reasons. In the United States, a combination of public unease, Roman Catholic opposition, federal democracy, judicial review, and critical scrutiny by the medical profession reversed the momentum of the eugenics movement and led to the conclusion that eugenic sterilization should be voluntary.
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Affiliation(s)
- A N Sofair
- Yale University, New Haven, Connecticut, USA
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14
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15
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Abstract
Clinical ethics, like bioethics more generally, until recently has tended to focus on the present and future, with little attention to the history of moral thought about health care that preceded bioethics. As a consequence, clinical ethics and bioethics lack maturity as fields of the humanities. The papers in this year's clinical ethics issue of the Journal put contemporary clinical ethics in critical dialogue with the past, making the former accountable to the latter. The six papers in this issue of the Journal are briefly described, with an emphasis on how they contribute to the maturation of clinical ethics as a field of the humanities.
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Affiliation(s)
- L B McCullough
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas 77030, USA.
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16
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Abstract
In this paper, I examine the notion of accountability and its historical evolution in health care. Using medical mistakes and adverse patient outcomes as my focus, I examine the interests served by particular models of accountability and argue for a model of collective fiduciary responsibility in U.S. health care today.
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Affiliation(s)
- V A Sharpe
- The Hastings Center, New York, New York 10524-5555, USA
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17
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Abstract
Childhood immunization constitutes one of the great success stories of American public health in the 20th century. This essay provides a historical examination of this topic through 4 particularly important examples: diphtheria, pertussis, polio, and measles. Each case study illustrates how new vaccines have posed unique challenges related to basic science, clinical trial methodology, medical ethics, and public acceptance. A brief comparison of each story to the experience of Great Britain, however, suggests an underlying unity connecting all 4 examples. Whereas the British led the way in introducing formal clinical trial methodology in the field of immunization development, the Americans excelled in the rapid translation of laboratory knowledge into strategies suitable for mass application. Although this distinction appears to have diminished in recent years, it offers insight into the sources of creativity underlying American vaccine development and the corresponding difficulties sometimes created for utilizing vaccines fruits rationally.
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Affiliation(s)
- J P Baker
- Department of Pediatrics, Duke University, Durham, NC 27710, USA.
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18
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Callahan D. Universalism & particularism. Fighting to a draw. Hastings Cent Rep 2000; 30:37-44. [PMID: 10742946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
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19
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Abstract
This article deals with the question how technology contributed to the performing of objective assessments of health risks and to the public trust in the insurance institution. Many authors have pointed to the relevance of medical or statistical technology with regard to the constitution of objectivity, because these technologies should be capable of diminishing the influence of social interactions--the "human element"--on the process of producing knowledge about health risks. However, in this article it is shown that the constitution of objective risk assessments and public trust cannot be seen as the product of one particular type of technology, but that it is the product of a socio-technical network, in which several heterogeneous elements become interrelated and interdependant. The historical reconstruction of this network also sheds a new light on the role of 'the human element' in the constitution of objectivity and trust. It shows that elements in the network which regulate the social interaction between the subjects involved are of no less importance to generate trust than technologies which tend to abstract from this interaction. In other words, objective and subjective elements are intertwined much more than is often recognized, and public trust is to a fairly large degree depends on conventions in social interaction.
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Affiliation(s)
- K Horstman
- Department of Health Ethics and Philosophy, University of Maastricht, The Netherlands.
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20
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Affiliation(s)
- M D Laubichler
- Program in History of Science, Princeton University, Princeton, NJ 08544, USA.
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21
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Abstract
It is argued that the current confusion about the role and purpose of the British nurse is a consequence of the modern rejection and consequent fragmentation of the inherited nursing tradition. The nature of this tradition, in which nurses were inducted into the moral virtues of care, is examined and its relevance to patient welfare is demonstrated. Practical suggestions are made as to how this moral tradition might be reappropriated and reinvigorated for modern nursing.
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Affiliation(s)
- A Bradshaw
- RCN Institute, Radcliffe Infirmary, Oxford
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22
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Affiliation(s)
- S L Gilman
- University of Chicago, IL 60637-1512, USA.
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23
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Affiliation(s)
- S Perry
- Medical Technology and Practice Patterns Institute, World Health Organization Collaborating Center on Health Technology Assessment, Bethesda, MD, USA
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24
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Affiliation(s)
- J A Gray
- Institute of Health Sciences, University of Oxford, Headington, UK
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25
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Abstract
In the move to critique managed care, the essential principles that first made it a reasonable alternative to fee-for-service medicine can easily be lost. Careful reflection on the history of early grassroots movements that created managed care, and on selected textual narratives of the founders of the managed care organizations at their inception, offers us insight into which of the critical premises and goals of that effort might be reclaimed as we analyze the current managed care environment.
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Affiliation(s)
- L Zoloth
- Department of Philosophy, San Francisco State University, California 94132, USA
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26
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Sidley P. South African doctors demand action on "unethical" colleagues. BMJ 1999; 319:594. [PMID: 10473468 PMCID: PMC1116486 DOI: 10.1136/bmj.319.7210.594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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27
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Affiliation(s)
- D J Kevles
- Division of Humanities, California Institute of Technology, Pasadena, CA 91125,
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28
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Abstract
This essay argues that Hume's theory of justice can be useful in framing a more persuasive case for universal access in health care. Theories of justice derived from a Rawlsian social contract tradition tend to make the conditions for deliberation on justice remote from the lives of most persons, while religiously-inspired views require superhuman levels of benevolence. By contrast, Hume's theory derives justice from the prudent reflections of socially-encumbered selves. This provides a more accessible moral theory and a more realistic path to the establishment of universal access.
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Affiliation(s)
- L R Churchill
- Department of Social Medicine, The University of North Carolina at Chapel Hill, 27599-7240, USA
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29
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Affiliation(s)
- J D McCue
- St Mary's Medical Center, San Francisco, CA 94117-1079, USA
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30
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Baum ME. Have we come a long way, baby? American abortion at the open and close of the twentieth century. Pharos Alpha Omega Alpha Honor Med Soc 1999; 62:20-3. [PMID: 10414131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Affiliation(s)
- M E Baum
- Johns Hopkins University School of Medicine, USA
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32
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Abstract
Women who test positive for a genetic breast cancer marker may have more than a 50% chance of developing the disease. Although past screening technologies have sought to identify actual breast cancers, as opposed to predisposition, the history of screening may help predict the societal response to genetic testing. For decades, educational messages have encouraged women to find breast cancers as early as possible. Such messages have fostered the popular assumption that immediately discovered and treated breast cancers are necessarily more curable. Research, however, has shown that screening improves the prognosis of some--but not all--breast cancers, and also that it may lead to unnecessary interventions. The dichotomy between the advertised value of early detection and its actual utility has caused particular controversy in the United States, where the cultural climate emphasizes the importance of obtaining all possible medical information and acting on it. Early detection has probably helped to lower overall breast cancer mortality. But it has proven hard to praise aggressive screening without exaggerating its merits. Women considering genetic breast cancer testing should weight the benefits and limitations of early knowledge.
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Affiliation(s)
- B H Lerner
- Center for the Study of Society and Medicine, Columbia University, New York, NY 10032, USA.
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33
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Abstract
The National Institutes of Health (NIH) and Food and Drug Administration (FDA) have both recently revised their policies regarding the inclusion of women in clinical trials. Pressured by women's health activists and members of Congress, the NIH has vastly improved its policies; it now requires that women and minorities the included in clinical trials and that an analysis of gender and racial differences be performed. The FDA policy states that women and men should be included in clinical trials if both would receive the drug when marketed and that it expects a gender analysis to be performed. The FDA also lifted its 1977 ban on including women of childbearing potential in the early phases of drug studies. Analyzing these NIH and FDA policies according to a gender justice framework, I find that the NIH has moved significantly toward the institution of gender justice as it applies to medical research policies and that the FDA has taken only small steps toward this goal and lags behind the NIH.
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Affiliation(s)
- K L Baird
- Purchase College, State University of New York, USA
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34
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35
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Affiliation(s)
- A L Fairchild
- Program in the History of Public Health and Medicine, Division of Sociomedical Sciences, The Joseph L. Mailman School of Public Health, Columbia University, New York, NY 10032-2625, USA.
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36
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Abstract
The history of electroconvulsive therapy (ECT) in the United States is traced from its crude beginnings in 1940 to its emergence as a highly sophisticated and effective treatment for many severe psychiatric disorders. The general distrust of all somatic therapies in the 1930s and 1940s expressed by many prominent psychiatrists (both analysts and nonanalysts) contributed to an ambivalent relationship between ECT and the rest of American psychiatry. The media coverage of ECT is reviewed, and suggestions for dealing with the antipsychiatry movement and anti-ECT prejudice are discussed.
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Affiliation(s)
- Z M Lebensohn
- Department of Psychiatry, Sibley Memorial Hospital, Georgetown University School of Medicine, Washington, DC, USA
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37
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Abstract
PURPOSE To create a more meaningful understanding of the informed consent process as it has come to be practiced and regulated in clinical trials, this discussion uses the experience gained from the conduct of therapeutic research that involves cancer patients. DESIGN After an introduction of the ethical tenets of the consent process in clinical research that involves potentially vulnerable patients as research subjects, background that details the use of written consent documents and of the term "informed consent" is provided. Studies from the cancer setting that examine the inadequacies of written consent documents, and the outcome of the consent process itself, are reviewed. Two ethically challenging areas of cancer clinical research, the phase I trial and the randomized controlled trial, are discussed briefly as a means of highlighting many dilemmas present in clinical trials. Before concluding, areas for future research are discussed. RESULTS Through an exclusive cancer research perspective, many current deficiencies in the informed consent process for therapeutic clinical trials can be critically examined. Also, new directions for improvements and areas of further research can be outlined and discussed objectively. The goals of such improvements and research should be prevention of further misguided or ineffective efforts to regulate the informed consent process. CONCLUSION To ignore this rich and interesting perspective potentially contributes to continued misunderstanding and apathy toward fulfilling the regulatory and ethically obligatory requirements involved in an essential communication process between a clinician-investigator and a potentially vulnerable patient who is considering clinical trial participation.
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Affiliation(s)
- C K Daugherty
- Section of Hematology-Oncology and the MacLean Center for Clinical Medical Ethics, University of Chicago, IL 60637-1470, USA.
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38
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Abstract
In the late 1950s and early 1960s, emerging advances in the biomedical sciences raised insufficiently noticed ethical issues, prompting science reporters to serve as a sort of Early Warning System. As awareness of bioethical issues increased rapidly everywhere, and bioethics itself arrived as a recognized discipline, the need for this early-warning press role has clearly diminished. A secondary but important role for the science journalist is that of investigative reporter/whistleblower, as in the Tuskegee syphilis trials and the government's secret plutonium experiments. Because the general public gets most of its information from the popular media, ways are suggested for journalists and bioethicists to work together.
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Affiliation(s)
- A Rosenfeld
- March of Dimes Birth Defects Foundation, White Plains, NY 10605, USA
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39
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Abstract
During the Nazi era, so-called euthanasia programs were established for handicapped and mentally ill children and adults. Organized killings of an estimated 70,000 German citizens took place at killing centers and in psychiatric institutions. Nurses were active participants; they intentionally killed more than 10,000 people in these involuntary euthanasia programs. After the war was over, most of the nurses were never punished for these crimes against humanity--although some nurses were tried along with the physicians they assisted. One such trial was of 14 nurses and was held in Munich in 1965. Although some of these nurses reported that they struggled with a guilty conscience, others did not see anything wrong with their actions, and they believed that they were releasing these patients from their suffering.
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Affiliation(s)
- S Benedict
- College of Nursing, Medical University of South Carolina, USA
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40
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Abstract
Eugenics casts a long shadow over contemporary genetics. Any measure, whether in clinical genetics or biotechnology, which is suspected of eugenic intent is likely to be opposed on that ground. Yet there is little consensus on what this word signifies, and often only a remote connection to the very complex set of social movements which took that name. After a brief historical summary of eugenics, this essay attempts to locate any wrongs inherent in eugenic doctrines. Four candidates are examined and rejected. The moral challenge posed by eugenics for genetics in our own time, I argue, is to achieve social justice.
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41
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Sullivan WM. What is left of professionalism after managed care? Hastings Cent Rep 1999; 29:7-13. [PMID: 10321334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
Modern American medicine has wedded scientific advance to a small business model of the individual practitioner, defining professionalism as technical understanding. If the profession is to survive, it must draw on older ideals of the learned professions as acting on behalf of the community, and reinvigorate a ovic understanding of professional life.
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Dreger AD. A history of intersexuality: from the age of gonads to the age of consent. J Clin Ethics 1999; 9:345-55. [PMID: 10029835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
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43
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Abstract
Since the 1940s the Draize test had been the standard
test applied to any substance that might conceivably get
into a human eye. The Draize test involved immobilizing
fully conscious rabbits in stocks so that they could not
scratch their eyes, and then applying the substance to
one eyeball of each rabbit. The eyeballs were examined
at intervals of, for example, 24, 48, and 72 hours, and
graded for damage such as blindness or blistering. In 1980
Henry Spira launched a campaign against the Draize test.
By taking out full-page ads asking Revlon why it was blinding
rabbits for the sake of beauty, he persuaded that company
to donate $750,000, over 3 years, to a search for alternatives
to the Draize test. Other leading cosmetics corporations
soon followed suit. By 1982 there were signs that progress
was being made. In July of that year Revlon reported that
it had established a panel to ensure that unnecessary Draize
tests are not performed, and as a result it had cut back
the number of rabbits it used annually in the Draize test
from 2,210 in 1979 to 1,431 in 1981. Avon adopted a policy
of always using local anaesthetics if there was any anticipated
discomfort for the animals. Bristol-Myers said that it
was using fewer animals than had been used in the classical
Draize test. All three of the companies were continuing
to contribute substantial sums to research programs designed
to find alternatives to the Draize test.
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Affiliation(s)
- P Singer
- Centre for Human Bioethics, Monash University, Clayton, Australia
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44
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Abstract
In both African and Asian colonies until the late 19th century, colonial medicine operated pragmatically to meet the medical needs first of colonial officers and troops, immigrant settlers, and laborers responsible for economic development, then of indigenous populations when their ill health threatened the well-being of the expatriate population. Since the turn of the century, however, the consequences of colonial expansion and development for indigenous people's health had become increasingly apparent, and disease control and public health programs were expanded in this light. These programs increased government surveillance of populations at both community and household levels. As a consequence, colonial states extended institutional oversight and induced dependency through public health measures. Drawing on my own work on colonial Malaya, I illustrate developments in public health and their links to the moral logic of colonialism and its complementarity to the political economy.
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Affiliation(s)
- L Manderson
- Australian Centre for International and Tropical Health and Nutrition, University of Queensland, Herston, Australia.
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45
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Abstract
The Titanic has become a metaphor for the disastrous consequences of an unqualified belief in the safety and invincibility of new technology. Similarly, the thalidomide tragedy stands for all of the "monsters" that can be inadvertently or negligently created by modern medicine. Thalidomide, once banned, has returned to the center of controversy with the Food and Drug Administration's (FDA's) announcement that thalidomide will be placed on the market for the treatment of erythema nodosum leprosum, a severe dermatological complication of Hansen's disease. Although this indication is very restricted, thalidomide will be available for off-label uses once it is on the market. New laws regarding abortion and a new technology, ultrasound, make reasonable the approval of thalidomide for patients who suffer from serious conditions it can alleviate. In addition, the FDA and the manufacturer have proposed the most stringent postmarketing monitoring ever used for a prescription drug, including counseling, contraception, and ultrasonography in the event of pregnancy. The Titanic/thalidomide lesson for the FDA and public health is that rules and guidelines alone are not sufficient to guarantee safety. Continuous vigilance will be required to ensure that all reasonable postmarketing monitoring steps are actually taken to avoid predictable and preventable teratogenic disasters.
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Affiliation(s)
- G J Annas
- Health Law Department, Boston University School of Public Health, MA 02118-2526, USA
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46
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Affiliation(s)
- J Herman
- Assia Community Health Centre, Netivot, Israel
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47
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48
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Affiliation(s)
- E A Friedman
- Department of Medicine, State University of New York, Health Science Center at Brooklyn 11203, USA
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49
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Affiliation(s)
- N Krieger
- Department of Health and Social Behavior, Harvard School of Public Health, Boston, Mass. 02115, USA.
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50
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Affiliation(s)
- M Meldrum
- National Institutes of Health, Bethesda, MD 20892, USA
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