Thesis (MPhil)--University of Stellenbosch, 2004. / ENGLISH ABSTRACT: This thesis discusses the value of medical futility as an action guide for neonatal endof- life decisions. The concept is contextualized within the narrative of medical progress, the uncertainty of medical prognostication and the difficulty of just resource allocation, within the unique African situation where children are worse off today than they were at the beginning of the last century. parties actively engage in an interactive deliberation for a plan of action. Both parties ought to accept moral responsibility. Such a model of deliberation has the added advantage of transcending the limitations of the participants to arrive at a higher-level solution, which is considered more than just a consensus. It has been argued that medical progress has obscured the basic need for human compassion for the dying and for their loved ones. The literature furthermore reports that the quality of end-of-life care is unsatisfactory for both patients and their families. It is within this context that the concept of medical futility is positioned as a useful action guide. As we do not have the luxury of withdrawing from the responsibility to engage in the deliberation of end-of-life decisions, such responsibility demands an increasing awareness of ethical dilemmas and a model of medical training where communication, conflict-resolution, inclusive history taking, with assessment of patient values and preferences, is focussed on. The capacity for empathetic care has to be emphasized as an integral part of such approach. Finally, in this thesis, the concept of medical futility is tested and applied to clinical case scenarios. It is argued that the traditional medical paradigm, with its justification of an 'all out war' against disease and death, in order to achieve utopia for all, is outdated. Death in the neonatal intensive care unit is increasingly attributed to end-of-life decisions. Futile treatment could be considered a waste of scarce resources, contradicting the principle of nonmaleficence and justice, particularly in an African context. The ongoing confidence in, and uncritical submission to the technological progress in medicine is understood as a defence and coping mechanism against the backdrop of the experience of life's fragility, suffering and the inevitability of death. Such uncritical acceptance of the technological imperative could lead to a harmful fallacy that cure is effected by prolonging life at all cost. What actually occurs, instead, is the prolongation of the dying process, increasing suffering for all parties involved. The historical development of the concept of medical futility is discussed, highlighting its applicability to the paradigmatic scenario of cardio-pulmonary resuscitation. Particular attention is given to ways in which the concept could endanger patient-autonomy by allowing physicians to make unilateral, paternalistic decisions. It is argued that the informative model of the patient-physician relationship, where the physician's role is to disclose information in order for the patient to indicate her preferences, ought to be replaced by a more adequate deliberative model, where both / AFRIKAANSE OPSOMMING: Hierdie tesis bespreek die waarde van mediese futiliteit as 'n maatstaf vir aksie in gevalle van neonatale 'einde-van-lewe' besluite. Die konsep word gekontekstualiseer binne die wêreldbeskouing van mediese vooruitgang, die onsekerheid van mediese prognostikering en die probleme wat geassosieer IS met regverdige hulpbrontoekenning; spesifiek binne die unieke Afrika-situasie. Dit word aangevoer dat die tradisionele mediese paradigma, met regverdiging vir voorkoming van siekte en dood ten alle koste, verouderd is. Sterftes in neonatale intensiewe sorgeenhede word toenemend toegeskryf aan 'einde-van-lewe' besluite Futiele behandeling sou dus beskou kon word as 'n vermorsing van skaars hulpbronne, wat teenstrydig sou wees met die beginsels nie-skadelikheid ('nonmaleficence') en regverdigheid. Die volgehoue vertroue in en onkritiese aanvaarding van aansprake op tegnologiese vooruitgang lil geneeskunde, kan beskou word as verdediging- en hanteringsmeganisme in die belewenis van lewenskwesbaarheid, lyding en die onafwendbaarheid van die dood. Sodanige onkritiese aanvaarding van die tegnologiese imperatief kan tot 'n onverantwoordbare denkfout, naamlik dat genesing plaasvind deur verlenging van lewe ten alle koste, lei. Wat hierteenoor eerder mag plaasvind, is 'n verlenging die sterwensproses en, gepaard daarmee, toenemende lyding van all betrokke partye. Die historiese ontwikkeling van die konsep van mediese futiliteit word bespreek met klem op die toepaslikheid daarvan op die paradigmatiese situasie van kardiopulmonêre resussitasie. Spesifieke aandag word gegee aan maniere waarop die konsep pasiënte se outonomie in gevaar stel, deur die betrokke medici die reg te gee tot eensydige, paternalistiese besluitneming. Die argument is dan dat die informatiewe model, waar die verhouding tussen die dokter en pasiënt gebasseer is op die beginsel dat die dokter inligting moet verskaf aan die pasiënt sodat die pasiënt 'n ingeligte besluit kan neem, vervang moet word met 'n meer toepaslike beraadslagende model, waar sowel die dokter as die pasiënt aktief deelneem aan interaktiewe beraadslaging oor 'n aksieplan. Albei partye word dan moreel verantwoordbaar. So 'n model van beraadslaging het die bykomende voordeel dat dit die beperkings van die deelnemers kan transendeer. Sodoende word 'n hoër-vlak oplossing - iets meer as 'n blote consensus - te weeg gebring. Die argument word ontwikkel dat mediese vooruitgang meelewing met die sterwendes en hul geliefdes mag verberg. Verder dui die literatuur daarop dat die kwaliteit van einde-van-lewe-sorg vir sowel die pasiënte as hul familie onaanvaarbaar is. Dit is binne hierdie konteks dat die konsep van mediese futiliteit kan dien as 'n maatstaf vir aksie. Medici kan nie verantwoordelikheid vir deelname aan beraadslaging rondom eindevan- lewe beluitneming vermy nie, en as sodanig vereis die situasie toenemende bewustheid van sowel die etiese dilemmas as 'n mediese opleidingsmodel waann kommunikasie, konflikhantering, omvattende geskiedenis-neming, met insluiting van die pasient se waardes en voorkeure, beklemtoon word. Die kapasiteit vir empatiese sorg moet weer eens beklemtoon word as 'n integrale deel van hierdie benadering. Ten slotte, hierdie tesis poog om die konsep van mediese futiliteit te toets en toe te pas op kliniese situasies.

Thesis (MPhil)--Stellenbosch University, 2000. / ENGLISH ABSTRACT: The community of the Western Cape carries the burden of the serious consequences of alcohol addiction. Alcohol abuse is very common and the consequences range from severe to devastating, not just for the individual but also for the family and the community as a whole. If answers are sought within the community, the problem deepens, and it becomes apparent why the problem of alcohol abuse is not being successfully addressed. The addict refuses treatment, the community respects the autonomy of the individual, and the problem drags on. The community also has many misperceptions concerning the causes and perpetuation of the pathological drinking behaviour of the addict, and are thus not equipped with the knowledge necessary to suggest the correct interventions for this physical and psychological illness. There is also concern that a person's autonomy and human rights are so highly regarded in the community that the appropriate treatment necessary for this serious disorder of addiction does not receive the attention it deserves. This paper investigates the causes of alcoholism and the factors which reinforce a person's drinking behaviour. The autonomy of the alcoholic is challenged and examined in depth. The importance currently assigned to autonomy and individual rights is questioned, and balanced against other important moral and ethical principles of our time. Alcohol is a drug which causes physical and psychological addiction. Addiction literally means "under the control" of something. Alcohol use is a socially acceptable habit. The psychotropic (calming) effect of alcohol serves as an effective support in or escape from stress in the life of the individual. There are also "vulnerable" individuals in the community in whom a genetic predisposition increases the chance of the development of alcohol dependence. In spite of the fact that alcohol dependence is an acquired physical condition, nobody intentionally becomes addicted to alcohol. With the knowledge of the power that addiction exercises over the life of the individual, attention is now given to the autonomy of the addict, and his/her capacity for rational decision making. The significance of the decision to request treatment for the individual, his/her family and the community is balanced against competency to take the decision. Argument is developed towards the conclusion that the alcoholic is indeed not autonomous, and does not have the competency to make decisions concerning treatment. If the autonomy of the addict is thus questioned, the way in which the person is then treated by the community becomes a difficult moral dilemma. The community's responsibility of care towards the individual and the wider community are jeopardized. The ethical principles of deontology (rules), utilitarianism (the best result for the greatest number), autonomy versus beneficence, solicitude, virtue, human rights and other principles are discussed in depth. A solution is sought that will eventually be "good" for the addict and the community. The conclusion is reached that it is "good" to intervene in the life of the addict at a certain stage of addiction. Involuntary treatment is suggested as one possible way of attacking the problem of serious alcohol abuse that is threatening to overwhelm the community. Practical suggestions are offered for the renewed application of existing treatment structures and legislation to the benefit of the addict and the community. / AFRIKAANSE OPSOMMING: Die gemeenskap in die Wes-Kaap gaan gebuk onder die ernstige gevolge wat alkoholverslaafdheid meebring. Alkoholmisbruik is baie algemeen en het ernstige tot vernietigende gevolge, nie net vir die induvidu nie, maar ook vir die gesin en die gemeenskap as geheel. As daar na antwoorde vir hierdie probleem in die gemeenskap gesoek word, verdiep die probleem en kom dit duidelik aan die lig waarom die probleem van alkoholmisbruik nie suksesvol aangespreek kan word nie. Die verslaafde persoon weier behandeling, die gemeenskap respekteer die indivdu sy · outonomiteit en die proble~m sleep voort. Die gemeenskap het ook baie wanopvattings omtrent die oorsake en instandhouding van die verslaafde se patologiese drinkgedrag en is dus nie met die nodige kennis toegerus om die korrekte ingrepe vir hierdie fisiese en psigiese siektetoestand voor te stel nie. Daar is ook kommer dat die gemeenskap 'n persoon se outonomiteit menseregte s6 hoog aanslaan dat 1 die toepaslike hantering van die ernstige verslawing nie tot sy reg kom nie. Hierdie werkstuk ondersoek die oorsake van alkoholisme en die faktore wat die persoon se drinkgedrag versterk. Die alkoholverslaafde se outonomiteit word uitgedaag en in diepte ondersoek. Die gewig wat 'n persoon se outonomiteit en 'regte' in die gemeenskap dra, word bevraagteken en met ander belangrike moreel etiese beginsels van die dag gebalanseer. Alkohol is 'n dwelm wat fisiese en psigiese verslaafdheid veroorsaak. Verslaafdheid beteken letterlik 'onder die beheer' van daardie substans. Alkohol gebruik is sosiaal 'n aanvaarbare gewoonte. Alkohol se psigotrope effek (kalmerend) dien as 'n effektiewe stut of ontvlugting vir stres in die lewe van die individu. Daar is ook 'kwesbare' individue in die gemeenskap waar 'n genetiese predisposisie die persoon meer 'vatbaar maak vir die ontwikkeling van alkohol afhanklikheid. Ten spyte van die feit dat alkohol-afhanklikheid 'n verworwe fisiese toestand is, raak niemand 'moedswillig' aan alkohol verslaaf nie. Met die kennis van die krag wat verslawing op die individua se lewe uitoefen as agtergrond word daar voorts gekyk na die outonomie en die verslaafde se vermoe tot rasionele besluitname. Die gewigtigheid van die besluit tot behandeling vir die individu, sy gesin en die gemeenskap word met kompetensie tot besluitname gebalanseer. Arguemente word gebou wat tot die gevolgtrekking lei dat die alkohol-afhanklike inderdaad nie outonoom is en nie die kapasiteit vir die neem van behandelingsbesluite besit nie. Indien die verslaafde se outonomiteit dan bevraagteken word, word die gemeenskap se verdere hantering van die persoon 'n groot morele dilemma. Die gemeenskap se verantwoordelikheid van sorg teenoor die individu en die groter gemeenskap kom in gedrang. Die etiese beginsels van deontologie (reels), konsekwensialisme (die beste vir die meeste), outonomiteit versus goedwilligheid, sorgsaamheid, deug, menseregte en ander beginsels word in diepte bespreek. Daar word voorgestel dat die gemeenskap se plig tot so~g, in die geval van endstadium alkoholisme, moreel sterker is as bloot die respek vir outonomie. Daar word tot die gevolgtrekking gekom dat dit 'goed' is om op 'n sekere stadium van verslawing in die lewe van 'n persoon in te gryp.· Nie-vrywillige behandeling word voorgestel as bloot een van die aanslae vanuit die gemeenskap om die ernstige probleem van alkoholmisbruik wat besig is om die gemeenskap te oorweldig aan te pak. Praktiese voorstelle word gemaak om huidige behandelingsstrukture en wetgewing opnuut tot voordeel van die verslaafde en die gemeenskap aan te wend.

Thesis (MPhil)--University of Stellenbosch, 2001. / ENGLISH ABSTRACT: Perhaps one of the most talked about subjects worldwide and in South Africa these days is the abortion issue. A growing number of women admit to having had one. Basically there are two opposing views and values on the question of abortion. We normally hear people referring to the 'abortion issue'; my understanding of this is that there is a dialogue going on at the moment concerning abortion. In South Africa before the current Choice of Termination of Pregnancy (TOP) Bill, some activists' women and the ever-growing 'feminists' movements were lobbying and demanding that abortion be decriminalised. As we may all be aware, up until 1 February 1997, abortion or termination of pregnancy (TOP) in South Africa was conceivable under very restrictive atmosphere. Before the introduction of the current Termination of Pregnancy Bill, a majority of women had no access to abortion services in the country, hence the growing number of back-street job. By implication this means that most women given the choice, would not seek the experience of abortion, but if they do, it would be available to the in safe, legal, accessible and affordable service. Not only does the Act conceal that terminating pregnancy that occurred through criminal acts such as rape and incest is justifiable. The current liberal Termination of Pregnancy Bill also gives pregnant women the 'right' or 'freedom' to abort whenever and for whatever reason they deem fit. Part of the ethical dilemma of the abortion issue is that there are those who holds a view that always where there is a conflict of rights and interests, the foetus' rights must give way to, or that the foetus' rights must be overridden by those of a pregnant women. Pro-choice advocates maintain that a woman's choice to terminate her pregnancy is her own business and hers alone, in other words, this for them is a private decision. Well, I argue that this is not necessarily the case, ethically, the father of the unborn child should also be considered in such a decision. Given that virtually every abortion has risks, the parents of the aborting woman and to some extent the society at large are involved. Therefore, to solely talk of the 'mother's right to choose' is basically suggest that morality is "relative" and such relativism is conceived from the idea of privatisation of abortion and life in general. In the following pages I will look at the arguments in support of abortion and against it, and these are criticised. Also discussed are the ethical implications of the new South African Termination of Pregnancy Act. Broadly speaking, technology advancement has made it possible to detect the unborn baby's physical condition (sometimes even its mental state) while the mother is still pregnant. The ethical implications of this medical intervention are used to decide whether the unborn child should live or die. Given this, if the purpose of these prenatal diagnosis were for the destruction of the unborn, therefore, advocates of the movements such as 'the right to life', and 'pro-lifers' would argue that because of particularly twisted purpose, prenatal diagnosis must be abolished. Furthermore, I will acknowledge that the Termination of Pregnancy Bill as we have it, is appraised by feminists movements and others who are not necessarily feminists as allowing increased and unrestricted access to 'free' and 'safe' abortion in the government hospitals and clinics. However, I argue that this was rather prematurely introduced. I argue that a number of pregnant women claiming to be poor still present themselves to private doctors and private clinics for abortion and they pay anything between R 600- 800 or more depending where these services are provided. On the other hand, for one reason or another, other women still choose to terminate their pregnancies back street way although the risks are high in such servicing stations. In the light of these facts, one wonders whether it is appropriate to legislate for the termination of pregnancy or would it have been a worthwhile decision to delay the legislation of abortion for a while and thoroughly make a research and relevant preparation for it. I also argue that ideology plays an important part in the abortion debates. Besides, the abortion debate is also characterised by indoctrination, the purpose of which is to leave other confused. In both cases facts are misrepresented or false statements are made, and this for me is ethically unacceptable. I will also comment on the importance of linguistics, that is, the proper understanding of normal English terms and what I refer to as 'deceptive language' used by campaigners. Inthe last part of this thesis, I will outline some basic approaches to ethics and which belong to what is referred to as postmodernism. The Postmodern worldview deconstructs metanarratives so that no one particular belief is more believable than another. This worldview bring with it ethical relativism, which is a theory which holds that morality is relative to the individual. Three movements are given as an example of this move toward ethical relativism, they are: (a) Emotivism, (b) Subjectivism, and (c) Situationalism While I will argue that rape and incest are evil acts, and support abortion in cases involving such acts, however, I also believe that abortion is not the answer to the problem of rape and incest. I will propose a number of recommendations the South African government should have made before legislating for abortion. For instance, by creating separate abortion service facilities even in the hospital premises, with properly trained staff; so that people who came to seek advice for abortion are not intimidated by those who go to full terms with their pregnancy. Included in this thesis is a case study to demonstrate the complexity of the abortion issue to everyone involved. Some psychological and emotional symptoms following abortion will be outlined and this according to women who do share their abortion story is a reality they have to live with every day of their lives. / AFRIKAANSE OPSOMMING: Aborsie is moontlik een van die mees veelbesproke kwessies van ons tyd, sowel in Suid- Afrika as wêreldwyd. 'n Groeiende aantal vroue erken dat hulle al een gehad het. Basies is daar twee opponerende gesigspunte en waardes betrokke by die twispunt rondom aborsie. Aborsie was voor die aanvaarding van die jongste wetgewing (d.w.s. voor 1 Februarie 1997) in Suid-Afrika slegs moontlik onder streng beperkings. Voor die huidige wet ( die "Termination of Pregnancy Bill") in werking gekom het, het die meerderheid vroue geen toegang tot aborsie gehad in Suid-Afrika nie, wat gelei het tot 'n toename in agterstraat aborsies. Die nuwe wet gee nie slegs die reg om te aborteer aan vroue wat swanger is as gevolg van kriminele optrede soos verkragting of bloedskande nie. Die huidige, buitengewooon liberale wet gee ook vir alle praktiese doeleindes aan die vroue die reg om aborsie op versoek te ondergaan tot op 20 weke van swangerskap. Die doel van hierdie werkstuk is om hierdie nuwe liberale wet aan 'n krities ondersoek te onderwerp. Deel van die etiese dilemma rondom die kwessie van aborsie spruit voort uit die feit dat daar diegene is wat reken dat, indien daar enige konflik tussen regte en belange is, die regte van die fetus ondergeskik is aan die regte van die swanger vrou. Diegene ten gunste van aborsie voer aan dat die keuse gemaak moet word deur die betrokke vrou, en dat so 'n keuse uitsluitlik haar eie is. Ek argumenteer dat dit nie noodwendig die geval is nie. Die vader van die ongebore kind behoort ook 'n sê te hê in hierdie saak. Gegee dat elke aborsie sekere risiko's insluit, het die ouers van die betrokke vrou en die samelewing ook 'n belang by so ,'n situasie. Dus is om slegs te praat van die 'vrou se reg om te Ides' om te suggereer dat moraliteit "relatief' is, en sulke relativisme word afgelei van die idee van die privatisering van aborsie en die lewe in die algemeen. In die volgende bladsye sal ek die argumente vir en teen aborsie analiseer en kritiseer. Die etiese implikasies van die nuwe Termination of Pregnancy Act word veral bespreek. Tegnologiese vooruitgang het dit moontlik gemaak dat die ongebore baba se fisiese (en soms selfs mentale) kondisie bepaal kan word voor geboorte. Die etiese implikasies van die mediese intervensie word gebruik om te besluit of die ongebore baba moet lewe of sterf Dus, indien die doel van prenatale diagnose die moontlike vernietiging van die ongeborene insluit, sal diegene wat teen aborsie is, argumenteer dat so 'n verwronge doel veroorsaak dat sulke ondersoeke gestaak behoort te word. Ek sal erken dat die nuwe wet waardeer word deur feministe, en andere wat nie noodwendig feministe is nie, as 'n wet wat dit moontlik maak dat daar toenemende en onbeperkte toegang is tot 'gratis' en 'veilige' aborsies in regeringshospitale en klinieke. Maar ek wil argumenteer dat die wet te vroeg aangeneem is. Ek argumenteer dat 'n groot aantal verwagtende vroue voorgee dat hulle arm is en poog om 'n aborsie te kry by private dokters en klinieke, en dan tussen R600 - R800 of meer betaal vir so 'n diens, afhangende van waar dit geskied. Aan die ander kant, om een of ander rede, kies sommige vroue steeds om hulle swangerskappe te termineer deur agterstraat-aborsies, ten spyte van die risiko's. Gegewe hierdie feit, wonder mens of dit gepas was on 'n wet in te stel aangaande die terminasie van swangerskap, en of dit nie beter sou wees om die wetgewing uit te stel tot volledige navorsing gedoen is en voorbereiding getref is nie. Ek argumenteer ook dat ideologie 'n belangrike rol speel in die aborsie-debat. Die aborsie-debat word ook gekenmerk deur indoktrinasie ten einde mense te verwar. In beide gevalle is daar die wanvoorstelling van feite of word valse stellings gemaak, wat eties onaanvaarbaar is. Ek salook kommentaar lewer oor die belangrikheid van taal, dws die korrekte verstaan van normale (Engelse) terme en wat ek na verwys as die 'misleidende taal' wat gebruik word deur sekere kampvegters betrokke by die debat. In die laaste deel van die werkstuk sal ek sekere basiese benaderings tot etiek ondersoek, veral dié wat na verwys word as "postmodernisme". Die Postmoderne gesigspunt dekonstrueer metanarratiewe sodat geen spesifieke oordeel langer meer geloofwaardig is as 'n ander nie. Hierdie gesigspunt word dan ook vergesel deur etiese relativisme, wat huldig dat moraliteit relatief is tot die individu. Drie bewegings word genoem as voorbeelde van hierdie beweging na etiese relativisme, nl: (a) Emotivisme, (b) Subjektivisme, en (c) Situasie-etiek Alhoewel ek argumenteer dat verkragting en bloedskande morele verkeerd is, en alhoewel ek aborsie in sulke gevalle voorstaan, glo ek nie dat aborsie 'n antwoord bied op die probleem van verkragting en bloedskande nie. Ek sal 'n aantal voorstelle maak aangaande wat eintlik moes gebeur het voor die regering die huidige aborsiewet aanvaar het. Byvoorbeeld, dat aparte aborsie-fasiliteite, selfs by die hospitaal en met opgeleide personeel, geskep moes word ten einde te voorkom dat diegene wat advies vra aangaande aborsie nie geïntimideer word deur persone wat nie wil aborteer nie. Ingesluit in hierdie studie is 'n gevallestudie wat die kompleksiteit van die kwessie rondom aborsie, vir al die rolspelers, demonstreer. Sekere emosionele en sielkundige simptome, veroorsaak deurdat 'n persoon besluit het om te aborteer, sal geskets word. Vir vroue wat 'n aborsie ondergaan het is hierdie 'n realiteit waarmee hulle elke dag moet saamleef

Thesis (MPhil)--Stellenbosch University, 2014. / ENGLISH ABSTRACT: Pre-eclampsia is a common and dangerous condition of pregnancy. During clinical care the sensitive obstetrician will frequently recognise moral ambiguity and ethical conflicts. It is important to understand the pertinent issues and find ways of resolving them. Counselling is an important element of modern medicine. In deciding which counselling model to apply, clinicians must consider many variables including the particular clinical scenario, strength of evidence, and the justifiable limits of paternalism and autonomy in a position of shared responsibility. Couples have a moral right to procreate even when the pursuit of pregnancy involves significant risks. However, with their understanding of care ethics as well as rights ethics, informed women are well placed to negotiate the extremes of these positions when deciding whether to risk a pregnancy or not. The concept of the “fetal patient” is a helpful one. An autonomous woman may choose to confer or deny this status to her previable fetus, while obstetricians must balance autonomy- and beneficence-based obligations to the pregnant woman with beneficence-based obligations to her fetus. Maternal behaviour that harms the fetus and future child is categorised as maternal-fetal conflict. However, any pregnant woman is morally required to avoid harming the fetus, if this can be done without sacrificing her own important interests. The term non-compliance implies a hierarchical nature in the doctor-patient relationship. This reduces patient agency, erodes trust and conflicts with informed choice. Although sometimes justified, this “label” generally does more harm than good. Expectant management of early pre-eclampsia recognises that neonatal intensive care is an expensive and limited resource. The ultimate goal of expectant management remains the safety of the mother and the delivery of a live infant who will not require intensive and prolonged neonatal care. This judicious use of neonatal intensive care improves distributive justice but by consenting to expectant management as an inpatient, the pregnant woman voluntarily restricts her freedom. The decision is morally undergirded by the value accorded to the viable fetus and the scientific evidence informing the decision. When an extremely preterm, growth restricted fetus requires delivery, resuscitation may become an issue for consideration. The distinction between withholding resuscitation in such cases, or initiating but later withdrawing care is morally irrelevant. Categories of optional and obligatory treatments are more helpful, but perinatologists must determine treatment thresholds through understanding the relevant data and ethics issues. Finally, women do not lose their rights when they become terminally ill. When an undelivered woman is declared brain dead following complications of pre-eclampsia, her doctors and family must formulate clear plans for her and her living fetus. She must still be treated with respect and her right to die with dignity not forgotten. Extension of somatic support to optimise the outcome of her fetus can be supported ethically provided that the fetus is at the threshold of viability, the support is not prolonged (distributive justice), advanced level support is available with a successful outcome likely, and that doctors and family are in clear agreement. / AFRIKAANSE OPSOMMING: Pre-eklampsie is ‘n algemene en gevaarlike toestand van swangerskap. Die verloskundige met ‘n fyn waarnemingsvermoë sal dikwels morele dubbelsinnigheid en etiese konflik tydens kliniese sorg erken. Dit is belangrik om die kernaspekte te verstaan en maniere te vind om dit op te los. Berading is ‘n belangrike komponent van moderne geneeskunde. Tydens besluitneming oor watter model van berading toegepas moet word, moet klinici ‘n aantal veranderlikes teen mekaar opweeg insluitend die spesifieke kliniese senario, sterkte van die getuienis, die geregverdigde perke van paternalisme en outonomie in ‘n posisie van gedeelde verantwoordelikheid. Die egpare het ‘n morele reg om voort te plant selfs wanneer die verlange na swangerskap betekenisvolle risiko’s inhou. Vrouens wat goed ingelig is, het die vermoë om die uiterstes van etiek van sorg en regte teen mekaar op te weeg wanneer hulle besluit om die risiko van swangerskap te loop. Die konsep van “fetus as pasiënt” kan wel tot verdere besluitneming bydra. Die outonome vrou mag self besluit of die fetus daardie status het. Aan die ander kant moet die verloskundige outonomie en goedwilligheid- (“beneficence”) gebasseerde verpligtinge teenoor die swanger vrou opweeg teen die goedwilligheid-gebasseerde verpligting teenoor haar fetus. Moederlike gedrag wat die fetus en toekomstige kind skend, word as ‘n moeder-fetus konflik beskou. Enige swanger vrou is egter moreel verplig om nie die fetus skade te berokken nie, mits dit gedoen kan word sonder die prysgawe van haar eie noodsaaklike belange. Die term “nie-inskiklikheid” (“non-compliance”) impliseer hiërargie in die dokter-pasiëntverhouding. Hierdie hiërargie doen afbreuk aan die besluitneming van die pasiënt, ondermyn vertroue en bots met ingeligte keuses. Alhoewel besluitneming op grond van hiërargies-gebaseerde gesag soms geregverdig is, veroorsaak hierdie kategorisering gewoonlik meer kwaad as goed. Afwagtende hantering van vroeë pre-eklampsie gaan van die standpunt uit dat neonatale intensiewe sorg ‘n duur en skaars hulpbron is. Die uiteindelike doel van afwagtende hantering bly die veiligheid en gesondheid van die ma en die verlossing van ‘n lewendige baba wat nie verlengde intensiewe- en neonatale sorg benodig nie. Hierdie oordeelkundige gebruik van neonatale sorg bevorder distributiewe geregtigheid, maar wanneer sy toestemming gee tot afwagtende behandeling as binnepasiënt, beperk die swanger vrou vrywilliglik haar vryheid. Hierdie besluit word moreel ondersteun deur die waarde wat aan die lewensvatbare fetus toegevoeg word en die wetenskaplike gronde waarop die besluit berus. Wanneer ‘n erge voortydse, groeivertraagde fetus verlossing benodig, word ressussitasie soms iets wat oorweeg moet word. Die onderskeid tussen die weerhouding van ressussitasie in sulke gevalle en die onttrekking van sorg waar dit aanvanklik begin is, is moreel irrelevant. Kategorieë van opsionele en verpligte behandelings is meer behulpsaam, maar perinatoloë moet die behandelingsdrempels bepaal deur die relevante data en etiek te verstaan. Laastens, vroue verloor nie hul regte wanneer hulle terminaal siek word nie. Wanneer die komplikasies van pre-eklampsie breindood van die vrou veroorsaak voor die verlossing van haar baba, moet haar dokters en familie duidelike planne vir die hantering van haar en haar fetus ontwikkel. Sy moet nogsteeds met respek behandel word en haar reg om met waardigheid te sterf, mag nie uit die oog verloor word nie. Verlenging van die ondersteuning van lewensfunksies om die uitkoms van haar fetus te verbeter, kan eties ondersteun word, mits die fetus na aan lewensvatbaarheid is, die ondersteuning nie te lank duur nie (distributiewe geregtigheid), gevorderde ondersteuning beskikbaar is met ‘n goeie kans vir suksesvolle uitkoms en dat die dokters en familie ten volle saamstem.

Chan, Mee Lee. / Thesis Ed.D. Chinese University of Hong Kong 2014. / Includes bibliographical references (leaves 195-205). / Abstracts also in Chinese. / Title from PDF title page (viewed on 21, December, 2016).

Since the end of the military dictatorship in 1989, Chile’s prolonged and arduous transition to democracy has continued. It has been more than a decade of political and social processes, full of uncertainties, doubts and compromises. It has been a transition marred by the political and economic remnants of the military dictatorship, by a highly restrictive and authoritarian legal and constitutional system, and by a political class, and, for a long period unable to introduce truly democratic changes. The dynamic of the Chilean transition has had a deep effect on many sections of the Chilean society, especially the media, traditionally one of the key spheres of public debate. The underlying argument of this work is that the Chilean transition to democracy, a political and economic phase achieved by negotiation and compromise, was not accompanied by the establishment of a more democratic, pluralistic media system. This thesis examines, from a multidisciplinary perspective, the context, the process and the development of the media during the first decade of the transition to democracy (1990-2000). Its fundamental objective is to understand the relationship between journalism, the media and the democratic political processes in a post-dictatorship society. / Doctor of Philosophy (PhD)

In recent years, the federal No Child Left Behind (NCLB) Act has increasingly had a major impact on daily decisions in schools, especially for principals' performance. Depending on the accountability rating, schools are in jeopardy of closing, and principals and teachers are at risk of being fired (McGhee [and] Nelson, 2005). As a result, it is increasingly difficult to make daily ethical decisions on behalf of students and teachers when much of the focus is on standardized testing and accountability. Therefore, the purpose of this study was to describe the leadership practices used by an elementary principal in her effort to balance accountability and ethics. Models of ethical, educational leadership including Servant Leadership, Transformational Leadership, Moral Leadership, Ethical Leadership, and Democratic, Ethical, Educational Leadership have described the practices implemented by ethical leaders. However, research concerning how an elementary principal is able to balance the pressures of accountability and ethical practices to meet the needs of the students, teachers, and parents is less prevalent. This qualitative single-case study of a principal in one high achieving, low socio-economic status elementary school examined the leadership practices in an accountability context. Semi-structured interviews, field notes of observations at the school, and relevant documents were collected and used as the data for the study (Marshall [and] Rossman, 1999). Findings revealed that a clear vision, positive relationships, honest communication, and school-wide systems lend strong support to teaching and learning. Meaningful curriculum, instruction, and assessment; caring, supportive relationships; and a student-centered school culture, are essential components of intended efforts to balance the pressures of accountability and the needs of the students. Resources, shared decision-making, and a culture of mutual respect and responsibility may lead school leaders to address the pressures of accountability and meeting the needs of the teachers. A welcoming environment, pertinent information in English and Spanish, and opportunities for parents and families to get involved are critical avenues to meet and address the concerns of parents. This information may generate recommendations to educational leaders and serve as suggestions for pre-service and in-service training programs which are designed to prepare future ethical school leaders. / text

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Paediatric clinical trials are crucial to ensure safety and efficacy of medicines in children. This study explored parents’ perceptions in Gaborone, Botswana, regarding children’s participation in clinical trials. One hundred participants completed a self-administered questionnaire. The results showed that 93% of the participants had a good knowledge of clinical trials; 74% thought that children would benefit from clinical trial participation; 63% would not enrol their children in clinical trials; 55% suggested that children should only be enrolled once they have reached the age of 18 years; and 71% reported that only children with an active disease should be enrolled. A large proportion (82%) reported that children’s participation should be voluntary, while joint parental consent was supported by 93% of responders. Regarding children’s assent 91% deemed respect for children’s assent essential, although 52% thought that children’s assent should not override the parental decision. There was a statistically significant correlation between finding clinical trials in general important and children’s participation in clinical trials (p=0.008, Fisher’s Exact Test), as well as the need for individual consent p<0.0001, Chi-Square). There was also a statistically significantly association between respondents, who would allow their children’s participation in clinical trials and who would encourage their family members and friends’ participation in clinical trials (p=0.0001, Chi-Square). An overwhelming 94% advocated for special regulations in Botswana to govern paediatric clinical trials. Almost all participants (99%) explicitly expressed the opinion that there should be global regulations for paediatric clinical trials. / Thesis (M.Soc.Sc.)-University of KwaZulu-Natal, Pietermaritzburg, 2012.

No abstract available. / Thesis (LL.M.)-University of Natal, Durban, 2001.