Selective abortion and gene therapy: reflections on human limits.

The potential impact of the Human Genome Project on selective abortion is considered here, as is human gene therapy. Themes of emphasis are broadly humanistic: human suffering, contingency, and perfection. The chief concerns of the article lie with selective abortion for less than serious reasons, and with the importance of avoiding efforts to "enhance" human beings by gene transfer methods. The style is widely interdisciplinary.

Religious content in the DSM-III-R glossary of technical terms.

The authors reviewed Appendix C of DSM-III-R, Glossary of Technical Terms, for its references to religion. Religion was referred to more frequently in this glossary than it is in psychiatric research. The authors conclude that although the Glossary uses religion in constructive or cautionary reminders, the high rate of illustrative case examples of psychopathology that involve religion in the Glossary indicates cultural insensitivity in interpreting religion.

Genetics, ethics, and Alzheimer disease.

This article considers the emerging research on Alzheimer disease (AD) genetics in relation to ethical questions surrounding presymptomatic and prenatal genetic testing. Given the rapid advance in AD genetics over the past 8 years, it is likely that the attention of clinicians and ethicists will increasingly turn to genetic issues. After a survey of current genetic knowledge, this article addresses 3 areas of likely ethical concern. While AD genetic screening programs are currently rare and restricted to specific pedigrees, they will become more common in the future. It is, therefore, imperative that society and clinicians begin to consider the ethical issues this raises.

Physician-assisted suicide in Alzheimer's disease.

This paper takes up the question of physician-assisted suicide (PAS) in Alzheimer's disease (AD), reviewing arguments for and against in a broad interdisciplinary context. Preemptive PAS-AD involving competent patients raises the further question of AD-euthanasia. The author concludes, after thorough assessment of the literature, that caution in moving toward AD-PAS is necessary. However, where PAS is legalized, it may be difficult to justify precluding people with AD from access.

Fairhill guidelines on ethics of the care of people with Alzheimer's disease: a clinical summary. Center for Biomedical Ethics, Case Western Reserve University and the Alzheimer's Association.

These guidelines summarize the content of meetings of family caregivers and individuals with dementia of the Alzheimer's type who identified and spoke on ethical issues in dementia care and who engaged in dialogue with an interdisciplinary and interprofessional group of individuals working in the field of Alzheimer's disease. This inductive method begins with attentive listening to the voices of the affected population and family members, in contrast with a theoretical and deductive approach to ethics.

Emerging antidementia drugs: a preliminary ethical view.

What ethical concerns regarding the application of new antidementia compounds are pertinent to the best interests of patients with Alzheimer's disease and their caregivers? Based on collected preliminary anecdotal accounts, these concerns are important and should be considered carefully by clinicians, researchers, and families.

Preventing schizophrenia and Alzheimer disease: comparative ethics.

Schizophrenia and Alzheimer disease are both diseases of the brain that involve genetic susceptibility factors and for which the prevention or delay of symptom onset are important research goals. This paper provides some comparisons between current preventive efforts in schizophrenia and Alzheimer disease, focusing on certain ethical features of these endeavors such as potential discrimination, misdiagnosis, and stigma.

Implantable hormonal contraceptives: emerging controversy.

There is an emerging policy debate over the inclusion of Norplant incentives in welfare reform. Even if women were guaranteed access to the implant and payment for its removal were assured, the possibility of increased human immunodeficiency virus infection would remain a strong argument against its use. Although this article focuses on Norplant, many of the arguments apply to other long-acting contraceptives that may become available in the future.

Selective abortion for familial Alzheimer disease?

Advances in human genetics will soon allow prenatal diagnosis of genetic conditions in the fetus that range from trivial to devastating. This commentary explores the concept of severity in genetic diseases and decisions regarding selective abortion. Familial Alzheimer disease is used as a model for the analysis of ethical issues raised by prenatal diagnosis and the subsequent termination of pregnancy. The genetics of the disease has yet to be elucidated, but this condition may be amenable to prenatal diagnosis in the near future, at least in some families. Abortion is a choice open to women in the United States; however, it is still desirable to discuss on purely ethical grounds pregnancy termination in the case of late-onset but severe diseases.

Future scenarios for the prevention and delay of Alzheimer disease onset in high-risk groups. An ethical perspective.

CONTEXT: Alzheimer disease (AD) presents a major scientific and social challenge in our aging society. Strategies to prevent or delay onset of symptoms, as well as to prevent the decline into the advanced stage, are urgently needed. While these strategies do not yet exist in a proven and clinically applicable form, the science is progressing rapidly. OBJECTIVES: The pre-eminent goal is to identify asymptomatic persons at high risk for AD and to then apply pharmacologic and lifestyle interventions that delay onset of disease. In this scenario, genetic susceptibility testing may eventually prove accurate enough to be of use in identifying at-risk individuals decades before probable onset, allowing maximal preventive efforts. Second, an important goal is to delay or prevent the onset of moderate and advanced AD through applying compounds that slow the progression of disease, thereby allowing patients to die of unrelated ailments of old age before they lose their capacities to recognize loved ones and to communicate by speech. CONCLUSIONS: This article provides a discussion of these strategies with attention to a variety of ethical issues that should be of concern to physicians and caregivers. An assessment of the scientific evidence for preventing or delaying AD should be coupled with values analysis.

DSM-III-R and religion.

The interpretation of religion in DSM-III-R contains considerable negative bias and contributes to unfair stereotypes of religious persons. Particularly new religious movements and religious conversion are unfairly interpreted under the DSM-III-R heading, 'Dissociative Disorder Not Otherwise Specified'. It is suggested that a more balanced and respectful interpretation of religion is needed in DSM-III-R, since psychiatry through its official nomenclature should not contribute to social intolerance of religious nonconformity.

Key issues in the ethics of dementia care.

This article discusses nine important medical ethical issues following the progression of irreversible dementia from diagnosis to dying. Issues include prevention, research, truth telling, advance planning, cognitive-enhancing drugs, driving restrictions, respectful caring, distribution, justice, and natural dying.

Alzheimer's disease. Ethics and the progression of dementia.

This article provides an overview of the ethical issues raised by the experience of progressive dementia of the Alzheimer type. The discussion follows the chronology of this progression, reviewing significant literature and, at times, offering normative resolutions. Guidelines on dementia ethics will be increasingly important for good care.

Alzheimer disease and the "then" self.

The authority of the intact self over the future severely demented self is based on notions of integrity and precedent autonomy. Despite criticism of this authority, the principle of precedent autonomy in the care of people with Alzheimer disease or other progressive and irreversible dementias retains its moral significance.

Comments on research in the social sciences pertaining to Alzheimer's disease: A more humble approach.

This paper suggests that social scientists should make greater efforts to study those questions that truly address the daily needs of the AD community; that they should be more creative in their approach to future care, especially with regard to the social implications of new anti-dementia drugs and other treatments that may alter the course of the disease; and that more research is needed with respect to end of life care, and the controversies surrounding the use of tube-feeding and antibiotics.

The moral challenge of children at risk: protective policies and pediatrics. A report of the Children's Services, Inc. Task Force of Greater Cleveland.

Social workers and pediatricians are among the professionals who share a society-wide concern with current public policies regarding the placement of children at extreme risk. A healthcare professional may successfully treat a child, only to learn later that this same child was the victim of a tragic incident of domestic violence after returning home. Such events are not uncommon, create considerable frustration for pediatricians, and demand an integrated interprofessional and interdisciplinary response. This report emerged from 6 months of task force dialogue with leaders of children's services programs, healthcare professionals, clergy, ethicists, and other community leaders in one major urban environment. It indicates innovative directions in children's protective services with regard to family preservation, foster care, residential care, and adoption. The latter two options could be used much more creatively than is the case currently. The report also asserts that far too few resources are being directed to this problem area.

Pituitary function after selective adenomectomy for Cushing's disease.

This retrospective analysis was undertaken to determine whether selective adenomectomy for Cushing's disease can achieve acceptable cure rates while causing minimal pituitary dysfunction. Tumour size, histology and pituitary function were evaluated in 34 consecutive patients (26 F:8 M, mean age 33.6 years) undergoing transsphenoidal adenomectomy for Cushing's disease from 1975 to 1992. Follow-up averaged 5.8 years. Cure was defined as resolution of symptoms and signs and normalization of urinary cortisol excretion. Sixty-three per cent of patients achieved cure after selective adenomectomy; repeat adenomectomy cured an additional four patients. Twenty-eight per cent required bilateral adrenalectomy and/or pituitary irradiation. Postoperative pituitary function remained completely intact in 81%. Secondary hypogonadism occurred in 8%, hypothyroidism in 15% and permanent diabetes insipidus in 4%. There was recurrence in 26% after a mean of 4.6 years (range 1-7). It is concluded that selective adenomectomy can achieve acceptable cure rates with a low prevalence of postoperative hypopituitarism, although an increase of recurrence may be the result of conservative surgery.

American culture and euthanasia. The changing definition of a "good death".

Divisions run deep in contemporary America over the issue of assisted suicide or mercy killing. The active, directly intended, and freely chosen self-destruction that was once unspeakable has become speakable. A recent best-seller providing "how-to" information on suicide; Initiative 119 in Washington State, which would allow "aid-in-dying"; and other publications and polls indicate that the proponents of mercy killing may have won over American culture, or at least established a dominant foothold. One of the chief criticisms of policies that permit mercy killing and assisted suicide is that they inevitably encourage suicide among those who are neither terminally ill nor suffering from physical pain. American culture is extreme in its desire to eliminate suffering. In a culture that can no longer depend on religious insights into human suffering, all kinds of preemptive strikes against suffering seem inevitable. The success of proponents of euthanasia is an indirect indictment of a healthcare system that fails to provide good palliative care and support. In our curative and rescue-oriented healthcare system, management of pain is not a priority. And our society also undervalues caring in its most basic sense. It is not so much death as the absence of caring and the denial of reality that may be the enemy. The desire to control pain has always been valid, but not the desire to press control so far as to directly cause death itself. Death by lethal injection is best understood as a tyranny of technological control.(ABSTRACT TRUNCATED AT 250 WORDS)

Family ethics in caring for newborns with impairments.

The technological advances of modern society mean that family members have expanded obligations to care for newborns with severe impairments, who would have died in previous eras. This biological imbalance has created a moral one as well, for to care is to be penalized. Often this moral heroism can be sustained as a vacation only in communities based on the ideal of Christian love. Severely impaired children impose great physical and emotional stress on their parents, which can push the parents to the limits if they are unable to tap into altruistic emotions. Historically, children were not accorded moral status in the West until the Christian influence brought them into the moral community and encouraged parental responsibility. To fulfill their obligations, perhaps parents should bring their child with impairments home and relinquish care only when they find the burden too great. They are obligated to try because they brought the child into existence (biological-causal argument), because this caring is a reflection of God's image, and because children have a moral claim on their parents. Limits to parental obligations exist when continued care would be psychologically destructive for the parents, would conflict with obligations to other family members, particularly siblings, or would be harmful to the child because the atmosphere is no longer nurturing and loving.

To care but never to prolong?

What levels of life-prolonging medical interventions, if any, are appropriate for moderately and severely demented older people? This opinion piece includes a recent study of physicians' attitudes, which helps focus the controversy and examine the varied opinions that exist both internationally and within particular countries.