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Perspective
From an Ethics of Rationing to an Ethics of Waste Avoidance
Bioethics has long approached cost containment under the heading of "allocation of scarce resources." Having thus named the nail, bioethics has whacked away at it with the theoretical hammer of distributive justice. But in the United States, ethical debate is now shifting from rationing to the…
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Perspective
What We Talk about When We Talk about Health Care Costs
Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly. Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help…
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Perspective
200th Anniversary Article: Patients and Doctors — The Evolution of a Relationship
The relationship between patients and doctors is at the core of medical ethics, serving as an anchor for many of the most important debates in the field. Over the past several decades, this relationship has evolved along three interrelated axes — as it is defined in clinical care, research, and…
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Perspective
Selling Bone Marrow — Flynn v. Holder
On December 1, 2011, in Flynn v. Holder, the U.S. Court of Appeals for the Ninth Circuit held that the ban on selling "bone marrow" that is part of the National Organ Transplant Act (NOTA) of 1984 does not encompass "peripheral blood stem cells" obtained through apheresis. This ruling means that…
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Perspective
Global Health: Stemming the Brain Drain — A WHO Global Code of Practice on International Recruitment of Health Personnel
The World Health Organization (WHO) estimates that the world faces a shortage of 4.3 million health professionals required for delivering essential health care services to populations in need. This shortage constitutes a major barrier to the provision of essential lifesaving health services, such…
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Editorial
Transplantation for Alcoholic Hepatitis — Time to Rethink the 6-Month “Rule”
Liver transplantation for alcoholic liver disease has been controversial since the advent of the procedure. The perception that alcohol-related liver disease is self-inflicted, combined with concerns about recidivism to alcohol use and poor adherence to post-transplantation care, has led the public…
Perspective
The Coming Explosion in Genetic Testing — Is There a Duty to Recontact?
The question of whether a duty exists to recontact patients about new genetic information has been debated for several decades without consensus, but the emergence of new technologies compels us to reconsider this complex matter. Ordering a "genetic test," such as a chromosome analysis or a search…
Health Law, Ethics, and Human Rights
Restrictions on the Use of Prescribing Data for Drug Promotion
Pharmaceutical manufacturers spend billions of dollars each year sending sales representatives, known as detailers, into physicians' offices. To promote their drugs, detailers show up at medical offices bearing product information and valuable drug samples. They also wield a third critical tool:…
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Sounding Board
Reforming the Regulations Governing Research with Human Subjects
In the wake of the scandal surrounding the Tuskegee syphilis study, Congress established the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The commission investigated and made recommendations regarding basic ethical principles guiding research with…
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Perspective
HIV Surveillance, Public Health, and Clinical Medicine — Will the Walls Come Tumbling Down?
The centrality of antiretroviral therapy for people with human immunodeficiency virus (HIV) infection is an established feature of the clinical response to HIV–AIDS. Now there is compelling evidence that such treatment can have a profound impact at the population level by reducing viral loads and…
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Perspective
The Doctor's Dilemma — What Is “Appropriate” Care?
Most physicians want to deliver "appropriate" care. Most want to practice "ethically." But the transformation of a small-scale professional service into a technologically complex sector that consumes more than 17% of the nation's gross domestic product makes it increasingly difficult to know what…
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Case Records of the Massachusetts General Hospital
Case 23-2011 — A 40-Year-Old Pregnant Woman with Placenta Accreta Who Declined Blood Products
Presentation of Case. Dr. Britta Panda (Obstetrics and Gynecology): A 40-year-old woman was seen by the maternal–fetal medicine service at this hospital at 22 weeks 2 days' gestation because of placenta previa and placenta accreta. Beginning at 12 weeks 1 day's gestation, the patient had received…
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Editorial
Prescriptions, Privacy, and the First Amendment
On April 26, the Supreme Court heard oral arguments in a case that, when it is decided this spring, will have important repercussions for the practice of medicine. At issue in William H. Sorrell, Attorney General of Vermont, et al. Petitioners v. IMS Health Inc. et al. is whether detailed…
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Perspective
Teaching Clinicians about Drugs — 50 Years Later, Whose Job Is It?
This year marks the 50th anniversary of the Kefauver hearings, the pivotal 1961 Senate debate that transformed prescription drug approval and use. When Senator Estes Kefauver (D-TN) introduced legislation to regulate the drug industry, the Food and Drug Administration (FDA) still did not have legal…
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Sounding Board
Equipoise and the Dilemma of Randomized Clinical Trials
In the 1980s, bioethics scholars defined the dilemma of randomized clinical trials as a central problem in clinical research ethics. How can physicians offer their patients optimal medical care at the same time that their treatment is selected by chance in the context of a randomized clinical…
Perspective
The Age-Old Struggle against the Antivaccinationists
Since the introduction of the first vaccine, there has been opposition to vaccination. In the 19th century, despite clear evidence of benefit, routine inoculation with cowpox to protect people against smallpox was hindered by a burgeoning antivaccination movement. The result was ongoing smallpox…
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Perspective
Health Hazards of “Don't Ask, Don't Tell”
In the federal judicial system and the U.S. Congress, the fight over the military's "don't ask, don't tell" policy regarding homosexuality goes on. In September, Judge Virginia Phillips banned enforcement of the policy, ruling that it violates gay, lesbian, and bisexual service members' equal…
Perspective
Up in the Air — Suspending Ethical Medical Practice
First I will define what I conceive medicine to be. In general terms, it is to do away with the sufferings of the sick, to lessen the violence of their diseases, and to refuse to treat those who are overmastered by their disease, realizing that in such cases medicine is powerless. — The…
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Editorial
Products at Risk
In this issue of the Journal, we publish the results of a clinical trial investigating step-up control in adult patients with asthma whose disease was not well controlled by low-dose inhaled glucocorticoids. This study, which compared the utility of treating such patients with inhaled tiotropium…
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Perspective
Resurrection of a Stem-Cell Funding Barrier — Dickey–Wicker in Court
Embryo research was born political. Expressions of shock and surprise at the August 23 ruling of federal district court judge Royce Lamberth enjoining federal funding of stem-cell research — which was based largely on his reading of an amendment to an appropriations bill — are thus not terribly…
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