The Emotions in Bioethical Decision-making.

In an era of evidence-based medicine and an increasing use of technology the question is raised again as to what extent emotions should play in medical and ethical decision-making. While clearly the correct facts in each case are a sine qua non for ethical decision-making, and one should evaluate each situation rationally in accord with accepted ethical principles, the appropriate role of the emotions in decision-making is gaining increased attention in part as a result of newer research in neuroethics. In end-of-life care there often exists a disconnect between the "rational" analysis by many philosophers and ethicists and the emotional reactions of many physicians and nurses with respect to the comparison between withholding and withdrawal of life-sustaining therapy. It is suggested that these attitudes of many health care workers should not be ignored because they represent a critical, almost universal, and laudable value of reluctance to take human life, a value so strongly ingrained in the ethos of the medical profession.

[FORCE-FEEDING OR LIFE-SAVING? - DEALING WITH HUNGER STRIKES IN ISRAEL].

INTRODUCTION: Force feeding of fasting hunger-striking prisoners is the subject of considerable controversy in Israel and elsewhere, posing a direct conflict between two basic ethical values: that of human life and respect for autonomy. The Israel Medical Association, as well as the World Medical Association, has taken the position that force feeding of such prisoners is an act of torture and is therefore unethical. However this paper presents an opposing view, which recently became the law in Israel, that, whereas the rights of prisoners to decree a hunger strike as a form of protest should be respected, if the prolongation of the strike reaches a stage of clear and present danger to the life and health of a prisoner, the saving of the prisoner's life must take precedence over considerations of autonomy. The paper present the steps that should be taken, including extensive and empathic efforts to persuade the prisoner to end his/her fast; gaining the approval of a hospital's ethics committee; and gaining the approval of a district court judge; the feeding is to be carried out in the most humane and sensitive manner as befitting a lifesaving procedure for any patient. This position is consistent with Israel's Basic Law: Human Dignity and Liberty, Israel's Patient Rights Law, Israel's "Do not stand idly by your fellow man's blood" Law, with several Israeli court decisions and in keeping with the dominant Israeli culture. Finally, instructions for physicians who object to such measures are discussed, ascertaining the freedom of conscience as well as preserving the life of the hunger-strikers.

Response to: 'Why medical professionals have no moral claim to conscientious objection accommodation in liberal democracies' by Schuklenk and Smalling.

The recent essay by Schuklenk and Smalling opposing respect for physicians' conscientious objections to providing patients with medical services that are legally permitted in liberal democracies is based on several erroneous assumptions. Acting in this manner would have serious harmful effects on the ethos of medicine and of bioethics. A much more nuanced and balanced position is critical in order to respect physicians' conscience with minimal damage to patients' rights.

Jewish Medical Ethics.

BACKGROUND: Jewish medical ethics is a term coined by the late Lord Rabbi Immanuel Jacobovits in the mid-20th century. Its principles and emphases differ in some significant ways from the currently accepted axioms in Western secular ethics. The emphasis is lesser on autonomy and more on the value of human life and on communitarianism. The Israel Patient's Rights Law reflects these differences from the Western norms.

Maimonides Reincarnated.

The writings of Maimonides, the 12th-century physician, Talmudic and philosophic scholar, are remarkably relevant for modern medicine. Whereas the specific medical recommendations are obviously outdated, Maimonides' perceptive insights into professional responsibilities and medical ethics remain as useful guides even in our postmodern era.

[Force-feeding of hunger-striking prisoners].

In contrast to the position of the World Medical Association and the Ethics Council of the Israel Medical Association, the author argues for forced-feeding of hunger-striking prisoners when their condition reaches a stage of danger of death or permanent injury. This position is based on the priority of human life over autonomy, and of a communitarian ethic. This position is supported by a District Court decision ordering the feeding of a hunger-striking prisoner, by a Supreme Court decision imposing surgery on a non-consenting prisoner, and in line with Israel's Patient's Right Law.

Willingness to treat infectious diseases: what do students think?

INTRODUCTION: Outbreaks of serious communicable infectious diseases remain a major global medical problem and force healthcare workers to make hard choices with limited information, resources and time. While information regarding physicians' opinions about such dilemmas is available, research discussing students' opinions is more limited. METHODS: Medical students were surveyed about their willingness to perform medical procedures on patients with communicable diseases as students and as physicians. Students were asked about their opinions regarding the duty to treat in such cases. RESULTS: 74% of respondents felt that by deciding to enter medical school they were morally obliged to treat any patient despite the risks. Students' willingness to treat as physicians is significantly higher than their willingness to treat as students. HIV was significantly the most tolerated disease with respect to performing mouth to mouth resuscitation. Among preclinical students, we found that willingness to treat during the later years is significantly greater than during the earlier years. Among clinical students, the opposite was observed. DISCUSSION: Students' greater willingness to treat as physicians is mostly attributed to perceptions of higher obligations as a qualified doctor. There is greater but not total willingness to perform resuscitation on patients with HIV relative to other diseases. The increased willingness of preclinical students and the decreased willingness of clinical students both emphasise the importance of patient-physician communication and ethics studies during medical school.

[Circumcision in male newborns--update].

Recently, there have been efforts in a number of countries to forbid the circumcision of infants and children. This position, which is based on alleged violation of autonomy and on serious harm to the infant or child, is not supported by the medical literature. Controlled studies have accumulated showing the major health benefits of circumcision of infants; there is a decrease in urinary tract infections, a virtual elimination of cancer of the penis, a reduction in HIV and HPV infections, as well as other sexually transmitted diseases, and perhaps, reductions in prostatic cancer and in uterine cervical cancer. The complications of the procedure are minimal, especially when performed in infancy. Recent studies have not confirmed the alleged reduction in sexual pleasure as a result of circumcision. Therefore, there is no justification, whatsoever, for attempts to forbid circumcision of infants. On the contrary, there seem to be good reasons to encourage such practices.

Synthetic biology: a Jewish view.

The discipline of synthetic biology may be one of the most dramatic advances of the past few decades. It represents a radical upgrading of humankind's ability to manipulate the world in which we live. The potential for benefits to society is enormous, but the risks for deliberate abuse or dangerous miscalculations are no less great. There are serious ethical issues, legitimate concerns for biosafety, and fears of bioterrorism. The ethical dilemmas posed are new and challenging and are being addressed by various groups and commissions. The present paper presents a Jewish approach to some of the ethical issues posed by this new technology. Judaism traditionally looks favorably on man as a co-creator with God and encourages research for the benefit of humankind. Thus it would have a positive attitude towards the current goals of synthetic biology. But in the Jewish tradition man is also charged with stewardship over nature and is admonished to preserve and nurture, not just to exploit and destroy. In line with the Presidential Commission on Bioethics, it would support a carefully weighed balance between the precautionary and the "proactionary" approaches.

Quo vadis, bioethics.

The recent paper by Giubilini and Minerva suggesting the ethical permissibility of infanticide of normal newborns, calling it "postbirth abortion," represents a dangerous deterioration of generally accepted ethical norms. Their proposal represents a clear example of the so-called slippery slope and we caution against abandoning the age-old traditions of the medical profession assigning intrinsic value to human life from birth. This article discusses the proposed concept, makes comparisons with earlier similar trends of thought, and highlights the dangers of the proposal.

[Physicians' strikes--ethical considerations].

Strikes in general represent a solution based on a form of coercion. Historically, the striker caused direct damage to his employer, who was responsible for the perceived unfair treatment of the employee. In the case of strikes in the public sector, the employer is generally not harmed, but innocent citizens suffer in order to pressure the government agencies, a questionable practice from an ethical viewpoint. Physicians' strikes have more serious ethical problems. They cause suffering and death to innocent citizens. They violate the ethical codes to which physicians have committed themselves as professionals, and they seriously impair the trust of the public in physicians. Better and more ethical ways to provide fair compensation for physicians must be employed, perhaps like those used for judges and members of the IDF.