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paradigm, with its justification of an 'all out war' against disease and death, in order to achieve utopia for all, is outdated.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)--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.

Thèse numérisée par la Division de la gestion de documents et des archives de l'Université de Montréal.

Thèse numérisée par la Division de la gestion de documents et des archives de l'Université de Montréal

Thesis (M.S.)--University of Michigan, 1993.

Thesis (M.S.)--University of Michigan, 1994. / Spine title: CNM and MD outcomes for pain control in labor.

Thesis (M.S.)--University of Michigan, 1993.

Thesis (M.S.)--University of Michigan, 1994. / Spine title: CNM and MD outcomes for pain control in labor.

Thesis (doctoral)--Swinburne University of Technology, 2006. / Title from PDF title page (viewed on Nov. 30, 2006). Includes bibliographical references (p. 177-188).

This study aims to analyze the obesity and its more extreme classification, morbid obesity, and also its forms of treatment, with emphasis on bariatric surgery, procedure that appears to solve the obesity problem, assuming often a magical character. Nowadays, the body plays a central role in life of the subject and it is the stage for changes that aim a perfect and healthy body. The medical discourse underlies this context when points out that the ideal body is healthy, providing higher quality of life and longevity to the subject. In this scenario, the obese is a deviant because it doesn´t have control over your body to achieve the healthy, it is far from the threshold of normality that medicine postulates. Treatments are attempting to program such body, through diet, exercise and, in more severe cases, drugs. Bariatric surgery is indicated when conventional treatment was unsuccessful and promises to reduce the IMC range for normal, improve comorbidities and consequently the quality of life of the subject. The main question of this work is what causes the subject to look for bariatric surgery. We got in the bariatric surgery program at the University Hospital of UFS to analyze the processes that occur in practice. Under the theoretical and methodological framework of psychoanalysis and focused on listening, we explored the field in the waiting room. The speeches of patients that were waiting consultation with the preparing team of the program, and others who already passed by, enriched this work. We concluded that the medical discourse can ignore the subject, their expectations and fears in this process, taking from him his involvement in the decision to perform surgery, and it ends up suggesting to the subject a form of treatment outwardly magical that cures obesity. / Esse trabalho se propõe a analisar o tema obesidade e sua classificação mais extrema, a obesidade mórbida, além de suas formas de tratamento, com ênfase na cirurgia bariátrica, intervenção cirúrgica que surge para solucionar o problema da obesidade, assumindo, muitas vezes, um caráter mágico. Na contemporaneidade, o corpo assume papel central na vida do sujeito e é palco para modificações que visam um corpo saudável e perfeito. O discurso médico embasa esse contexto ao pontuar que o corpo ideal é o saudável, por proporcionar maior qualidade de vida ao sujeito e maior longevidade. Nesse cenário, o indivíduo obeso é um desviante, pois por não ter domínio sobre seu corpo para o alcance do saudável, ele se situa longe do limiar de normalidade que a medicina postula. Os tratamentos são a tentativa de reprogramar tal corpo, através de dietas, de exercícios físicos e, em casos mais graves, de medicamentos. A cirurgia bariátrica é indicada quando o tratamento convencional não teve sucesso e promete reduzir o IMC para uma faixa dentro da normalidade, melhorar as comorbidades e, consequentemente, a qualidade de vida do sujeito. A grande questão desse é o que leva o sujeito a procurar a cirurgia bariátrica. Inserimo-nos no programa de cirurgia bariátrica do Hospital Universitário da UFS para analisar na prática os processos ocorridos. Sob o referencial teórico-metodológico da Psicanálise e dispostos a escutar, exploramos o campo na sala de espera. As falas dos pacientes que aguardavam consultas com a equipe de preparação do programa, além de outros que por ali passavam, enriqueceram o trabalho. Chegamos à conclusão que o discurso médico pode desconsiderar o sujeito, suas expectativas e medos nesse processo, retirando dele sua implicação na decisão de realizar a cirurgia, à medida que acaba sugerindo ao sujeito uma forma de tratamento aparentemente mágica que cura a obesidade.