Mistreatment experienced by women delivering in healthcare institutions is a concerning pattern reproduced and normalized in health systems globally, causing widespread harm. Women’s reports and observations of childbirth practices in institutions have revealed that disturbing proportions of deliveries are characterized by indignity, humiliation, and neglect. The enormity of the problem constitutes a social catastrophe, as potentially hundreds of thousands are affected daily at a profoundly important moment of personal, family, and social life. Growing global concern has elicited research on mistreatment’s prevalence and characteristics, with limited attention to developing explanatory theory. The observed patterns indicate that mistreatment is systemic; therefore, social theory is required to understand why mistreatment persists, despite official norms that prohibit mistreatment and promulgate respectful care. Diane Vaughan’s normalization of organizational deviance theory from organizational sociology, emerged from studies of how things go wrong in organizations. The theory posits that organizational structures and processes are distorted due to resource scarcity combined with production pressures resulting in normalized organizational deviance in daily micro-level transactions. Furthermore, regulatory systems are unable to capture and mitigate the problem. Vaughan’s multi-level framework provided an opportunity for analogical cross-case comparison to elaborate theory on mistreatment as normalized organizational deviance.To elaborate the theory, the Tanzanian public health system in the period of 2010-2015 was selected as a case because it was the site of a seminal study to measure the prevalence of mistreatment, explore its causes, and develop and test interventions to reduce its occurrence. My participation in designing and conducting this study provided understanding of the phenomenon which formed the foundation of this dissertation. Novel theory was first elaborated through a systematic review of literature on maternal health care and the government health system in Tanzania. A broad Scopus search identified 4,068 articles published on the health system and maternal health in Tanzania of which 122 were selected. Data was extracted using a framework based on the theory and reviews of mistreatment in healthcare. Relationships and patterns emerged through comparative analysis across concepts and system levels and then were compared with Vaughan’s theory and additional organizational theories, resulting in a nascent theory. A qualitative theory-driven approach was then applied to verify and expand the nascent theory using qualitative exploratory data from the study in Tanzania described above. The data included eight focus group discussions and 37 in-depth interviews involving 91 individuals representing community and health system stakeholders. Data were analyzed deductively and inductively using the theory’s framework while allowing for emergent constructs. Analysis based on the literature review revealed that normalized scarcity at the macro-level combined with production pressures that emphasized biomedical care and imbalanced power-dependence on limited financial sources altered values, structures, and processes in the health system. Meso-level actors strove to achieve production goals with limited autonomy and insufficient resources, resulting in workarounds and informal rationing. Biomedical care was prioritized, and emotion work was rationed in provider interactions with women, which many women experienced as disrespect. The nascent theory developed through literature review was largely supported by the qualitative data, while providing further nuance and elucidating new components. Moral distress, which occurs when one knows the right thing to do but is prevented from taking the right action due to institutional constraints, emerged as an important systems effect of organizational dysfunction. In addition, the qualitative data revealed that managers coped with dual roles as both managers and providers and that the service interaction includes families, not solely providers, women, and newborns. The challenges in the regulatory environment also were clarified, highlighting that monitoring and observing mistreatment was hindered due to structural secrecy and the nature of mistreatment. The nascent theory revealed the importance of emotional labor and emotion work in understanding mistreatment. Emotional labor has been widely acknowledged as an important aspect of healthcare provision, especially for a positive patient experience; yet there has been limited attention to emotion work as the underlying effort required to provide respectful maternity care and prevent mistreatment. Qualitative data from the exploratory formative research were further analyzed to explore the characteristics of emotion work. 22 interviews and 3 focus groups with 44 maternity providers from different levels of care provision in two districts were analyzed using thematic analysis combined with affinity diagramming. Six key themes were identified that provide a deeper understanding of the emotion work required of maternity providers, including 1) expected to love and care for patients; 2) controlling emotions; 3) managing patient expectations in the face of system shortages; 4) providers are human beings too; 5) nurses are perceived as harsh; and 6) limited system support for emotion work. The themes and corresponding sub-themes highlight that the nature of childbirth care, the context, and gender norms influence the ability to exert emotion work and thus provide respectful care. Emotion work was expected but good performance was unacknowledged by the system. Additional resources are required, not only to ensure the most basic of resources to provide quality of care, but to ensure sufficient organizational support to address the emotional demands of providers. Systems need to acknowledge the extra effort required for emotion work and support and train providers to provide this care, as well as help them to manage difficult emotions that they experience due to the nature of their work. Analogical comparison with another case of organizational deviance enabled a novel approach to elaborate theory. Normalization of organizational deviance proved useful for understanding mistreatment. This theory and others from organizational sociology that explore why things go wrong in organizations may be relevant for other areas of persistent systems failure and underperformance. Further theory testing in different contexts and types of health systems is needed to understand the generalizability of the nascent theory and advance its development. In addition, many of the constructs, such as emotional labor and moral distress, have not been widely applied in low- and middle-income settings and require deeper study. This theory reveals the systemic factors driving mistreatment and can guide the identification of system leverage points to transform health systems towards ensuring a respectful experience during childbirth for women and their newborns. Ensuring that adequate resources are provided to achieve targets is essential, but organizational support to address the emotional demands of providers must also be provided. These changes will ease the burden among providers and managers struggling to provide care in under-resourced health systems. The extra effort required for emotion work should be acknowledged and appropriate training provided, as well as support for providers to manage the difficult emotions that they experience due to the nature of their work. The findings may also have implications beyond childbirth, as the theory highlights the conditions that may lead to burnout and poor mental health among providers, an ongoing problem worldwide that was exacerbated by the COVID-19 pandemic.

Law / LL.M.

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, 2005. / ENGLISH ABSTRACT: The complex ethical dilemmas created by advanced technological medicine and problematic doctor-patient relationships have lead to an increasing interest in medical ethics education since the 1980's. The Medical School of the University of Pretoria has embarked on a new undergraduate medical curriculum in 1997. Ethics is educated in a longitudinal fashion over the six years of the medical curriculum and has focussed largely on the principal-based approach as described by Beauchamp and Childress. The research participants were the first final year class of this new curriculum, while the facilitators were medical educators or philosophers. The major finding was that the students were not yet able to identify ethical dilemmas with ease, although they were successful in the application of the principal-based approach to the vignettes of the study. The students did not cope well with the uncertainty created by ethical dilemmas and sought to solve the situation by creating boundaries provided by medical law. Therecommendations of the study are that the theoretical component of the ethics curriculum should: 1) include more approaches to ethics, than only the principal-based approach; 2) address daily experienced ethical dilemmas during the study years in small group discussions; 3) and implement a portfolio assessment which can serve as a tool for students to track their own development in reflection on ethical dilemmas. In conclusion, the question remains whether we are currently ready to come ""face to face" with the "other" as Levinas argues or are we still divided into "only two classes of mankind in the world - doctors and patients" as remarked by Kipling in the 19th century. / AFRIKAANSE OPSOMMING: Die komplekse etiese dilemmas, veroorsaak deur hoogs gespesialiseerde tegnologiese medisyne en die problematiese dokter-pasiënt verhouding, het gelei tot 'n verhoogde belangstelling in mediese etiekonderrig sedert die 1980's. Die Mediese Skool van die Universiteit van Pretoria het in 1997 'n nuwe voorgraadse mediese kurrikulum geïmplimenteer. Etiek is op 'n longitudinale manier onderrig oor ses jaar in die mediese kurrikulum en het gefokus op die beginsel-benadering soos beskryf deur Beauchamp en Childress. Die navorsingsdeelnemers was die eerste finale-jaar klas van die nuwe kurrikulum, terwyl die fasiliteerders mediese dosente of filosowe was. Die hoofbevinding van die kurrikulum was dat die studente nie die etiese dilemmas met gemak kon identifiseer nie, alhowel hulle suksesvol die beginsel-benadering kon toepas op die gevallestudies. Die studente hanteer nie onsekerheid, veroorsaak deur die etiese dilemmas, met gemak nie en probeer om die saak op te los deur die skep van grense verskaf deur mediese reg. Die aanbevelings van die studie is dat die teoretiese komponent van die etiekkurrikulum die volgende moet bevat: 1) bekendstelling aan meerdere benaderings tot die etiek, bo en behalwe die beginsel-gebaseerde benadering; 2) aanspreek van die daaglikse etiese dilemmas gedurende die studiejare in kleingroepbesprekings; 3) en die implementering van 'n portfolio-evaluasie, wat kan dien as 'n instrument vir die studente om hul eie ontwikkeling aangaande nadenke oor etiese dilemmas na te gaan. Opsommend, die vraag is steeds of ons tans gereed is om "aangesig-tot-aangesig" te verkeer met die "ander" soos Levinas redeneer of is ons steeds verdeel in "slegs twee klasse van menswees in die wêreld - dokters en pasiënte" soos opgemerk deur Kipling in die 19deeeu.

Thesis (MPhil)--University of Stellenbosch, 2002. / ENGLISH ABSTRACT: Introduction From the postmodern ethical perspective [the postmodernist would say Jrom the ethical perspective], there is something suspicious and inherently unethical in a system of ethics supported by a comprehensive, cohesive and universal metanarrative, a set of fixed and unbending ethical rules and laws, without the ready possibility of revision [Cilliers, 1998, pp.114, 137-140; Cilliers, 2001, p. 3; Cilliers, 1995, p.125]. Based on the ideas of especially Winkler [1993, pp. 343-365] I have concluded that contemporary mainstream biomedical ethics, represented and directed by the work of Beauchamp and Childress [1994] are caught in such a crush. The primary objective of this assignment is to evaluate the 'principles' of biomedical ethics [respect Jar autonomy, beneficence, non-maleficence and justice] which were developed in their water-shed publication [Principles of Biomedical Ethics, Oxford University Press, first published in 1979, and now in a fifth edition, 2002] against a background of postmodern ethics. Methodology and conclusions I have argued that Beauchamp and Childress' conception of principlism is a contextual legalistic-philosophical response to the contemporary American situation, developed primarily from legal decisions [often litigation]. It may be regarded as acceptable practice guidelines, but represents a system of ethics without morality. I have given a concise rendering of Winkler's notion of context-based bioethics with the criticism that this also does not guarantee morality. Following that, there is a description of postmodern society in terms of complexity theory. I have indicated how the characteristics of complexity can be developed and applied contextually in bioethics. The postmodern moral society is the locus where morality develops in a non-controllable agonistic interactive process within which the postmodern moral agent unintentionally finds himself. The postmodern ethical position is not an unethical, come-as-you-may anything-goes position; it simply is not predictable, controllable, universal, rational [in a Kantian context] and eternal. Modernity, it can be argued exhibits a far greater degree of relativism. The postmodern ethical position represents a return to morality in ethics, morality of a very personal, face-to-face responsibility from which we as participants of society cannot hide. From a postmodern ethical perspective, an analysis of principlism and its underlying principles exhibits the characteristics of modernity: eternal moral rules which as such cannot be presented as morality. I have acknowleged Beauchamp and Childress' attempts at adding morality to their conception [in the 4th edition] by means of employing character ethics. They have nevertheless not made any radical changes in the format of their presentation and maintain the central and primary role of principles. I have also argued the limitations of the postmodern approach in terms of enclaves of strictly controlled modernity and artificial witholding of information in medicine which limit the free flow of information essential to the postmodern approach. My conception of complexity and the postmodern approach do not pretend to be a panacea for biomedical ethics. It attempts to redefine the meaning of morality in bioethics and questions the unbridled application of this conception of principIism. Finally I have discussed the burning issue of justice in the practice of medicine from the postmodern perspective. Do I as a person have a right to health care; what are the moral issues of dealing with 'life's lotteries'; what is the state's responsibility in health care, and: what are my personal responsibilities in health care? In contradistinction to libertarian concepts, the postmodern approach clearly argues in favour of the acceptance by the state of its role in health care [a responsibility abrogated in many societies, none more so than contemporary South-African society]. / AFRIKAANSE OPSOMMING: Inleiding Daar IS uit die perspektief van die postmoderne etiese standpunt [die postmodernis sou sê, uit die etiese perspektiej], iets verdags, iets inherent oneties aan 'n sisteem van etiek wat 'n enkele goed omskrewe, kohese en omvattende universele metanarratief voorhou, 'n stel vaste en onbuigsame etiese reëls en wette voorskryf en afdwing sonder om konteks en gevolge te oorweeg, en sonder die geredelike moontlikheid van revisie [Cilliers, 1998, pp.114, 137-140; Cilliers, 2001, p. 3; Cilliers, 1995, p.125]. Dit is, n.a.v. die denke van veral Winkler [1993, pp. 343-365] my oortuiging dat die hoofstroom-denke in biomediese etiek in so 'n drukgang vasgevang is, en verteenwoordig word en gerig is deur die denke van Beauchamp en Childress [1994]. Hierdie werkstuk gaan in hoofsaak daarom om Beauchamp en Childress se toepassing van die beginsels van biomediese etiek soos sedert 1979 in hul waterskeidingsboek 'Principles of Biomedical Ethics' [Vierde uitgawe, Oxford University Press, 1994; daar is nou ook 'n vyfde, 2002] uiteengesit, ontwikkel, bespreek en gepropageer [respek vir outonomie, weldadigheid, non-kwaadwilligheid en geregtigheid] teen die agtergrond van 'n postmoderne etiese beskouing te evalueer. Metodologie en gevolgtrekkings Ek het in hierdie werkstuk aangetoon dat Beauchamp en Childress se weergawe van prinsiplisme 'n kontekstuele wetlik-filosofiese reaksie op die kontemporêre Amerikaanse situasie is, hoofsaaklik uit regsaksie [dikwels litigasie] voortvloei, as goeie praktyksriglyne beredeneer kan word maar etiek sonder moraliteit verteenwoordig. Ek het 'n kort uiteensetting van Winkler se weergawe van 'n konteks-gebaseerde benadering gegee, maar aangetoon dat ook dit nie moraliteit waarborg nie. Daarop het ek 'n beskrywing van die postmoderne samelewing n.a.v. kompleksiteitsteorie gegee, en aangetoon hoe die eienskappe van kompleksiteit kontekstueelontwikkel kan word om in bioetiek toegepas te word. Die postmoderne gepostuleerde morele gemeenskap is die lokus waar moraliteit ontstaan deur 'n onbeheerbare agonistiese proses van interaktiewe wisselwerking waarby die postmoderne morele agent homself onwillekeurig betrokke vind. Die postmoderne etiese posisie is nie onetiese, lukraak, doen-soos-jy-wil relativisme nie; dit is bloot nie 'n voorspelbare, ewige, beheerbare, universele en [Kantiaans-] rasionele sisteem nie; moderniteit is [was?] in effek veel meer relativisties. Die postmoderne etiese standpunt verteenwoordig in my interpretasie 'n terugkeer tot moraliteit in etiek, moraliteit van 'n persoonlike, ingrypende, verantwoordelike aangesigtot- aangesig aard waaraan ons nie kan ontkom nie. Vanuit 'n postmoderne etiese perspektief het ek 'n analise van prinsiplisme en die individuele beginsels gemaak, en aangetoon dat hulle die eienskappe van die 'ewige morele reëls' van moderniteit openbaar en nie sonder meer as morele beredenering voorgehou kan word nie. Ek het erkenning gegee aan Beauchamp en Childress se eie pogings om dit te besweer deur karakteretiek as 'n essensiële tot hul formule toe te voeg, maar die kritiek uitgespreek dat hulle desnieteenstaande hierdie belangrike erkenning, nie bereid is om die formaat van hul aanbieding [ook in die jongste vyfde uitgawe, 2002] radikaal te wysig nie. Hulle oorbeklemtoon die beginsels steeds as sentraal en primêr. Terselfdertyd het ek die beperkings van die postmoderne benadering uitgelig, veral in terme van enklawes van streng-beheerde moderniteit in geneeskunde en 'n kunsmatige weerhouding van die vrye vloei van informasie wat kompleksiteit en die postmoderne situasie kenmerk. My konsepsie hou nie kompleksiteit en 'n postmoderne benadering voor as 'n panakeia vir biomediese etiek nie; dit dien eerder om die betekenis van moraliteit in bioetiek te herdefinieer en die kontemporêre algemene en ongekwalifseerde toepassing van hierdie weergawe van prinsiplisme te bevraagteken. Laastens het ek die brandende vraag van geregtigheid in die praktyk van geneeskunde vanuit 'n postmoderne perspektief bespreek, veral of ek as persoon kan aanspraak maak op 'n reg tot gesondheidsorg, die morele implikasies van 'life's lotteries', die staat se verantwoordelikheid in gesondheidsorg en les bes, persoonlike verantwoordelikheid in gesondheidsorg. Dit is duidelik dat 'n postmoderne benadering tot bioetiek, in teenstelling met libertêre konsepsies, die staat se rol in gesondheidsorg onderskryf ['n rol wat die staat byna universeel, en veral in Suid-Afrika, verwaarloos].

Thesis (MPhil)--University of Stellenbosch, 2003. / ENGLISH ABSTRACT: The health of the medical profession hangs in the balance. Scepticism, mistrust and legal restraints have entered its hallowed corridors and are threatening its integrity and independence. There are myriad seemingly intractable moral dilemmas that doctors, ethicists and judges are trying to resolve with the aid of available principles and rules of ethical discourse; yet, the answers remain elusive. Hegel, the eighteenth century philosopher, postulated that perplexity only exists because we do not look at the world correctly: because we tend to think in an oppositional way, we abstract from the complex interrelation of things. He therefore suggested that one should step back and think reflectively about the problem and seek the one-sided assumptions that led to the impasse. My proposition is that at the heart of many of the current medical dilemmas lies the opposition between paternalism and autonomy. These two fundamental concepts arose out of two different traditions, and now, because they have been abstracted from the contexts and histories that inform them, seem to be diametrically opposed. Paternalism arose out of the ethics of competence that originated in ancient Greece. The art of medicine was still in its infancy and physicians had to prove their ability and benevolence to a mistrustful public. Demonstration of competence became a necessary component of any successful practice. As the power of medicine grew with the scientific and technological advances of the Enlightenment, professionals' authority and competence were reinforced and systematically fostered a paternalistic attitude at the expense of adequate protection of the individual. In response to the power differential found in the political and social arena, individual human rights were promulgated in the eighteenth century. In the medical sphere, the culture of rights was translated into, among others, the fundamental right to autonomy. Patients now have the right to decide on interventions and treatment in accordance with their own conception of a good life. Paternalism thus developed out of a societal system that embraced the virtues and communal responsibility within the bounds of the polis of antiquity; autonomy arose out of the designs of the Enlightenment where the individual was hailed supreme. Remnants of both traditions are evident in contemporary medicine, but they have been abstracted from their original purpose and meaning, leading to perplexity and antagonism. Following the Hegelian method of dialectic, I postulate a thesis of paternalism, and in response to this, an antithesis of autonomy. I attempt to show that an intransigent insistence on one side or the other will only serve to strengthen the paradox and fail to lead to an acceptable solution. I aim to develop a synthesis where both concepts are embraced with the help ofa better understanding of human nature and the inevitable limits of human knowledge. Influenced by the work of the psychoanalyst Carl Jung, I firstly argue for the existence of a biological human need for compassion and thus the importance of virtue ethics, which embraces this need. Secondly, focusing on the ethics of futurity developed by Hans Jonas, I delineate the altered nature of human action and the derivative need for an ethics of responsibility. I propose possibilities for the future based on the ideas of compassion, virtue and responsibility and argue that they can only be reconciled in a pluralistic ethic. / AFRIKAANSE OPSOMMING: Die mediese professie het'n dokter nodig. Een wat kan sin maak van die wantroue en vyandigheid wat te bespeur is in die pasient-dokter verhouding en wat toepaslike terapie kan voorskryf Al die pogings tot behandeling deur middel van reëls, regulasies en etiese kodes het tot dusver misluk en het vele skynbaar-onoplosbare morele dilemmas agtergelaat. Die Duitse filosoof, Hegel, het in die agtiende eeu aangevoer dat verwarring onstaan bloot omdat ons die wêreld op die verkeerde wyse beskou: die mens is geneig tot opposisionele denke en neem daarom nie die komplekse onderlinge verbintenisse van die onderskeie elemente in ag nie. Hegel het dus voorgestel dat wanneer ons met sulke hardnekkige situasies gekonfronteer word, ons 'n tree terug neem en die situasie reflektiewelik ondersoek vir eensydige veronderstellings. My hipotese is dat baie van die etiese dilemmas wat op die oomblik in medisyne voorkom, voortvloei uit die opposisie tussen paternalisme en outonomitiet. Hierdie twee fundamentele beginsels het uit twee verskillende tradisies ontstaan en nou, omdat hulle nie meer in hulle oorspronklike konteks voorkom nie, vertoon hulle skynbaar teenstellend. Paternalisme het onstaan vanuit die etiek van bevoegdheid wat teruggevoer kan word na die tyd van Hippocrates. Medisyne was 'n nuwe professie wat nog sy eerbaarheid en welwillendheid aan 'n wantrouige publiek moes bewys. Bevoegdheid was dus 'n essensiële komponent van enige suksesvolle praktyk. Indrukwekkende vooruitgang in die dissiplines van wetenskap en tegnologie sedert die agtiende eeu het dokters se gesag en bevoegdheid bevorder en stelselmatig 'n paternalistiese houding gekweek ten koste van toepaslike beskerming van die individu. In respons tot die magsverskil in die politieke en sosiale sfeer het 'n beweging in hierdie tyd ontstaan om universêle mensseregte te bewerkstellig. In medisyne het hierdie regsbeweging gekulmineer in, onder andere, die fundamentele reg tot self-beskikking - in ander woorde, outonomiteit. Die pasient is dus nou geregtig daarop om selfte besluit oor ingrepe en behandeling op grond van sylhaar konsep van 'n goeie en sinvolle lewe. Paternalisme het dus ontstaan uit 'n samelewing waar die deugte en gemeenskapsverantwoordelikhede integraal was tot die funksionering van die polis; outonomie aan die ander kant, het ontstaan uit die idees van Die Verligting waar die individu as belangriker as die gemeenskap geag is. Volgens die Hegeliaanse dialektiese metode, postuleer ek dus 'n tesis van paternalisme en in respons daartoe, 'n antitese van outonomiteit. Ek voer aan dat 'n eiewillige aandrang op een of die ander die dilemma net sal verdiep. Ek poog dus om 'n sintese te ontwikkel wat albei konsepte inkorporeer met behulp van 'n analise van die aard van die mens en die noodwendige beperkinge van sy kennis. Geskool op die werk van die psigoanalis Carl Jung, bespreek ek die mens se biologiese behoefte aan medelye en stel dus die saak vir die belang van 'n etiek van deugte wat hierdie behoefte onderskraag. Tweedens, beinvloed deur die etiek van die toekoms, soos beskryf deur Hans Jonas, ontwikkel ek die idee van die gewysigde skaal van menslike dade en gevolglik die noodsaklikheid van 'n etiek van verantwoordelikheid. Ek postuleer dus 'n benadering wat wentel om die konsepte van medelye, deug en verantwoordelikheid wat slegs in die vorm van 'n pluralistiese etiek tot uiting kan kom.

This dissertation examines Peter Singer's proposed ethical value of the "person" in Rethinking Life and Death . Chapter 1 introduces and outlines Singer's proposal, which argues for abortion, infanticide, euthanasia, and assisted suicide. His proposal consists of four key points. First, there is the foundation for his proposal--rejecting creation for evolution. Second, there is the substance of his proposal--replacing the value of the "human" with the value of the "person." Third, there is the criteria for his proposal--using "indicators" and "relevant characteristics" to identify the kinds of beings who qualify as "persons." Fourth, there are the consequences of his proposal--promising an ethical "Copernican Revolution." Chapters 2-5 critically evaluate the four key ideas from Singer above. The evaluation of the respective key idea in each chapter covers five steps: (1) the context of Singer's proposal; (2) the content of Singer's proposal; (3) positive evaluation; (4) negative critique; and (5) conclusion. The research methodology for the dissertation is to treat Singer's ethical proposal on the "person" as a hypothesis to be tested by his own truth standards of logical consistency, empirical evidence, and practicality. Following these four key chapters, Chapter 6 provides "Summary and Conclusions." The conclusion of this dissertation is that Peter Singer's proposal on life and death is not to be commended because its key elements are not supported by his own standards for testing truth. In fact, when examined by his own truth tests, Singer's program should be rejected because its foundation is faulty, its substance is illusory, its criteria are circular, and its consequences would be grave. / This item is only available to students and faculty of the Southern Baptist Theological Seminary. If you are not associated with SBTS, this dissertation may be purchased from <a href="http://disexpress.umi.com/dxweb">http://disexpress.umi.com/dxweb</a> or downloaded through ProQuest's Dissertation and Theses database if your institution subscribes to that service.

Orientador: Alessandro Lia Mondelli / Resumo: A relação do médico com o paciente é uma relação de consumo. E com base na proteção consumerista, todas às obrigações do fornecedor de serviço devem ser obedecidas sob pena de responsabilização. Apesar da discussão quanto às naturezas das obrigações conforme responsabilidade de meio e fim, ou de natureza objetiva e subjetiva; todas as atuações profissionais conforme a legislação - independente de curativa ou estética – incidem regras do direito do consumidor. A crescente judicialização e processos iniciados contra médicos demonstra o desconhecimento da legislação aplicável. Em confronto aparente de normas ente o Código de Defesa do Consumidor vigente, que se apresenta como incidente, e o Código de Ética Médica, afirmando categoricamente não se tratar de relação de consumo prevalece, para o direito, indiscutivelmente aquele. E os Tribunais Estaduais e o Superior Tribunal de Justiça pacificamente entendem desta forma. Juntamente com a relação de consumo, várias obrigações comumente não entendidas pelos profissionais da medicina como sendo obrigatórios, passam, portanto, trazer consequências. Elas têm sido alvo de declarações de indenização. Neste aspecto particular surgem situações para o fornecedor, profissional médico, como prestação de contas, prestação de orçamento, obrigação da informação completa e possibilidade de inversão do ônus da prova no processo. Ademais, não tem validade na prática, cláusulas como, não indenizar, consentimento genérico, escolha do foro para questõ... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: The doctor's relationship with the patient is a relationship of consumption. And based on consumer protection, all obligations of the service provider must be obeyed under penalty of liability. In spite of the discussion about the nature of the obligations as responsibility of means and ends, or of objective and subjective nature; according to the legislation, all medical professional performances - regardless of curative or aesthetic - affect consumer rights rules. The increasing judicialization and proceedings against physicians demonstrates the lack of knowledge of the applicable legislation. In an apparent conflict of norms between the current Consumer Defense Code, which is presented as an incident, and the Code of Medical Ethics, categorically stating that it is not a relation of consumption, it indisputably prevails. And the State Courts and the Superior Court of Justice peacefully understand this way. Along with the relationship of consumption, several obligations commonly not understood by medical professionals as being mandatory, therefore, have consequences. They have been the subject of compensation claims. In this particular aspect, there have been situations for the supplier, for the medical professional, such as accountability, provision of budget, full information obligation and possibility of reversing the burden of proof in the process. In addition, clauses such as, no indemnification, generic consent, choice of forum for legal issues, transfer of liability ... (Complete abstract click electronic access below) / Mestre

Made available in DSpace on 2016-01-26T12:51:34Z (GMT). No. of bitstreams: 1 eudesquintinodeoliveirajunior_tese.pdf: 1111369 bytes, checksum: 88b0f45321dd3ad4e873ab99dd8ef6ed (MD5) Previous issue date: 2010-08-31 / Bioethics, a term that was coined for the first time in 1970 by the North American oncologist Van Rensselaer Potter, is a multidisciplinary science with the purpose of discussing varied aspects of the human life, raising the man on the top of the pyramid to decide regarding the conduct that is more appropriate, convenient and constructive for his own life project. The will autonomy, as the marker principle of the life science, is the feasible mechanism that will provide the best choice to reach the objectives of the person's accomplishment. The BioLaw, for its turn, derived from the bioethical perspective, is considered like a regulator device of the scientific progress, with the special objective to protect and to check safety to both the health and life, either human, animal being or vegetable. The Biotechnology and the Biotechnoscience with immeasurable progress offer, in short time, resources so that the man can have a better quality of life. But the scientific productions, not all of them salutary and convenient for the human being, need regulation. The BioLaw accounts for the juridical reading, as a parameter of the constitutional principles, among them with relevance, the human being's dignity. In the linking of the Bioethics and BioLaw, it is searched the answer to the issues that sharpen and challenge the man not yet prepared and who does not have promptly a definition on the acceptance or rejection of conducts that can break the ethical consensus or the use of techniques incompatible with the expectation of the individualized life. Several themes will cause further social, ethics, cultural and juridical changes among research such as: research involving adult and embryonic stem cells; different approved techniques for the accomplishment of medically assisted procreation; the substitutive maternity; the genetic patrimony; the synthetic cell; the understanding of the recombinant DNA; the allowed abortion, anencephaly fetus and the woman's procreative option; the transgender surgery and their consequences in the civil life; the scientific research with human beings and the CEP/CONEP System; the therapeutic and scientific cloning; the blood transfusion and the right to the faith faced with the right to life; the right to death dignity and the palliative cares provided by euthanasia, disthanasia , ortothanasia and assisted suicide; the homoaffective relationship and their legal implications; the Inventory for Elderlies and the longevity; the donation and transplantation of organs and human tissues; the beginning and the end of human life, and others. The present work aims to demonstrate the reach of the autonomy of the human will facing with new presented challenges. Or if the volition, in the extent of its individuality, with the burden of the rational, by itself, has effectiveness to reject or to accept the scientific progress. / A bioética, termo que foi cunhado pela primeira vez em 1970 pelo oncologista norte-americano Van Rensselaer Potter, apresenta-se como uma ciência multidisciplinar com a finalidade de discutir variados aspectos da vida humana, alçando o homem no topo da pirâmide para que possa decidir a respeito da conduta que seja mais adequada, conveniente e construtiva para seu projeto de vida. A autonomia da vontade, como o princípio balizador da ciência da vida, é o mecanismo racional que irá proporcionar a escolha da opção mais correta para se atingir os objetivos de realização da pessoa. O biodireito, por sua vez, fruto do pensamento bioético, coloca-se como um dispositivo regulador dos avanços científicos, com o objetivo especial de proteger e conferir segurança à saúde e à vida, quer seja humana, animal ou vegetal. A bioteconologia e a biotecnociência, com avanços imensuráveis, oferecem, em curto espaço de tempo, recursos para que o homem possa ter uma qualidade melhor de vida. Mas as produções científicas, nem todas salutares e convenientes para o ser humano, necessitam de regulação. O biodireito encarrega-se da leitura jurídica, tendo como parâmetro os princípios constitucionais, dentre eles com relevância o da dignidade da pessoa humana. Na junção da bioética e biodireito busca-se a resposta para os temas que aguçam e desafiam o homem ainda despreparado e que não carrega de pronto uma definição a respeito da aceitação ou rejeição de condutas que podem quebrar o consenso ético ou da utilização de técnicas que venham a ser incompatíveis com a expectativa da vida individualizada. As pesquisas envolvendo células-tronco adultas e embrionárias; as variadas técnicas aprovadas para a realização da procriação assistida; a maternidade substitutiva; o patrimônio genético; a célula sintética; a decifração do DNA recombinante; o aborto permitido, o de feto anencéfalo e o proveniente da opção procriativa da mulher; a cirurgia de transgenitalização e suas consequências na vida civil; as pesquisas científicas com seres humanos e o Sistema CEP/CONEP; a clonagem terapêutica e científica; a transfusão de sangue e o direito à crença diante do direito à vida; o direito à dignidade da morte oferecidos pela eutanásia, distanásia, ortotanásia e suicídio assistido; as uniões homoafetivas e suas implicações legais; o Estatuto do Idoso e a longevidade; a doação e o transplante de órgãos e tecidos humanos; o início e o fim da vida humana, são dentre muitos outros, temas que provocarão mudanças sociais, éticas, culturais e jurídicas. O presente trabalho procura demonstrar o alcance da autonomia da vontade humana diante dos novos desafios apresentados. Ou se a volição, no âmbito de sua individualidade, com a carga do racional, por si só, tem eficácia para repudiar ou aceitar os avanços científicos.

Made available in DSpace on 2016-04-27T13:10:23Z (GMT). No. of bitstreams: 1 Adilson Peron.pdf: 1186813 bytes, checksum: 5ebb7419e0360630b3d63cef39acfe9f (MD5) Previous issue date: 2014-02-12 / Introduction: Cholelithiasis is very prevalent surgical disease, with approximately 60,000 admissions per year in the Unified Health System in Brazil (Sistema Único de Saúde - SUS). Is often asymptomatic or oligosymptomatic and major complications arise from the migration of calculi to biliary low tract. Despite these complications are severe and life threatening, many patients refuse surgical treatment. Objectives: To understand the reasons why individuals with cholelithiasis refuse cholecystectomy before complications inherent to the presence of gallstones in the bile duct and pancreatitis occur. Methods: To investigate the justifications for refusing to submit to surgery we performed individual interviews according to a predetermined script. In these interviews, we evaluate the degree of knowledge of individuals about the disease and its complications and the reasons for the refusal of surgical treatment. We interviewed 20 individuals with cholelithiasis who refused or postponed surgical treatment without a plausible reason. In these interviews, we apply the thematic analysis (MINAYO, 2006). Results: The majority of participants has good knowledge of their disease and its possible complications, were well oriented and had the right surgical indications by their physicians. The refusal for surgery is based primarily on negative experiences of themselves or family members with surgery, including anesthesia; unexplained fears of surgery and, some, cannot specify the reason for the denial or prefer to get the risk and wait for complications to then have to solve them compulsorily. Conclusions: The reasons for the refusal to surgical resolution of cholelithiasis are diverse, but are closely related to personal negative surgical experiences or related persons or complex problems of psychological nature that must be adequately addressed by the surgeon and other qualified professionals. Our study has the proposal of an informed consent that brings all the information about the surgery, its preoperative and postoperative risks, as well as figures with friendly format intended to inform and to help the patients in their decisions / Introdução: A colelitíase é uma doença de resolução cirúrgica muito prevalente, com aproximadamente 60.000 internações por ano no SUS. Muitas vezes é assintomática ou oligossintomática e as principais complicações advêm da migração dos cálculos para as vias biliares baixas. Apesar das complicações serem graves e com risco de morte, muitos pacientes se recusam ao tratamento cirúrgico. Objetivos: Entender as razões pelas quais os indivíduos com colelitíase recusam a colecistectomia antes que ocorram complicações inerentes à presença de cálculos na vesícula, nas vias biliares e a possível pancreatite. Métodos: Para conhecer as justificativas da recusa à cirurgia realizamos entrevistas individuais segundo um roteiro de perguntas pré-determinadas. Nestas entrevistas procuramos avaliar o grau de conhecimento dos indivíduos sobre a doença e suas complicações e as razões para a recusa do tratamento cirúrgico. Entrevistamos 20 indivíduos portadores de colelitíase que se recusavam ou adiavam sem uma justificativa plausível o tratamento cirúrgico. A estas entrevistas aplicamos a análise temática (Minayo, 2006). Resultados: A grande maioria dos entrevistados tem bom conhecimento de sua doença, das possíveis complicações, foram bem orientados e tiveram a indicação cirúrgica pelos seus médicos assistentes. A recusa para a cirurgia foi baseada (principalmente) em experiências negativas próprias ou de familiares com o ato cirúrgico, incluindo aí a anestesia; medos inexplicáveis do ato cirúrgico e alguns não conseguiram especificar a razão para a recusa, preferiram correr o risco e esperar pelas complicações para então ter que resolvê-las. Conclusões: As razões para a recusa à resolução cirúrgica da colelitíase são diversas, mas estão intimamente ligadas às experiências cirúrgicas negativas pessoais ou de pessoas relacionadas ou a complexos problemas de natureza psicológicas que devem ser adequadamente abordados pelo cirurgião e por outros profissionais habilitados. Nosso estudo faz a proposta de um termo de consentimento livre e esclarecido que traz todas as informações sobre a cirurgia, seus riscos pré e pós-operatório assim como figuras com formato amigável que pretendem informar e ajudar o paciente na sua decisão.