Adults, those over the age of eighteen, are presumed competent and therefore enjoy a certain level of autonomous decision-making free from outside intrusion. Those who have not reached the age of majority, on the other hand, are presumed incompetent, and thus require the aid of parents or guardians to assist in the decision-making process. Recent studies in adolescent development suggest that certain individuals, though not yet eighteen, have the requisite competence to make informed, autonomous medical decisions. In turn, some states have acknowledged the mature minor doctrine, which is based on the seemingly simple principle that minors who demonstrate a sufficient level of maturity ought to have their choices respected independent of third parties. Though many agree that certain adolescents reason on a level equal to that of young adults, debate surrounds the conclusion that minors should be permitted to consent to or refuse medical treatment especially when the choice has life or death consequences. A further complication exists when the decision is based upon religious beliefs. To date, the relevant literature focuses on parents' religious beliefs that influence medical decision making for their minor children, and minors' maturity to decide medical care for themselves. Although some courts and scholars have addressed these topics in the same document, little attention has been paid to the unique circumstances involved when adolescents attempt to refuse life-saving or sustaining medical treatment based upon their expressed religious beliefs. Failing to address the religious maturity of the minors in question creates the possibility that they will be permitted to die for beliefs that are not truly their own. The thesis of this paper is that under these circumstances practitioners must inquire into the authenticity of the religious beliefs of the adolescents. Because the religious upbringing of children is directed by the beliefs of their parents and ministers it is necessary to ensure that the adolescents have developed their own underlying and enduring aims and values. Thus, these adolescents should have the burden to demonstrate clearly and convincingly that they understand their beliefs, as well as the consequences of the medical decision. Only then can practitioners be sure that the minors, independent of third party influence or coercion, have the ability to make an autonomous decision to die for those beliefs in line with their true sense of well-being.

In a highly influential piece supporting a patient's right to choose euthanasia, Dan Brock uses an incomplete notion of autonomy in one of the key premises to his argument. He defines autonomy as the individual's ability to pass judgment on the value of his/her own life, using his/her established set of values, and then to act accordingly. The respect that others should have for the patient's autonomy is then seen as primarily the negative 'letting alone' of the patient. Brock identifies autonomy, in this sense, to be a necessary element in a person's 'dignity.' In other words, suffering, terminally ill patients who do not have the freedom to determine the amount of suffering they experience before death, or to decide the timing and manner of their death, are seen to be 'undignified.' What this view leaves out is the necessary analysis of how patients go through the process of their life assessments, the intrinsic relational nature of this process, and how respect for autonomy and dignity understood in a broader sense can be seen to entail obligations to foster positive opportunities and beneficial circumstances for terminally ill persons, rather than acquiescence to their demands. One of the most biting criticisms of this account of autonomy comes from a type of feminist bioethical thinking called 'the ethics of care.' The ethics of care aims to replace the false moral ideal of the masculine, atomistic, emotionless individual who seeks control with a feminine, interdependent, emotional individual who seeks positive relationships. However, the ethics of care goes too far in its opposition to the importance of autonomy in the moral life of the individual. There is a better concept of autonomy that simultaneously defends the individuality of the person deciding (free from coercion) and the interdependence of that person on others in that person's: 1) formation of values, 2) deliberation or assessment of how to decide based on those values, and 3) following through with the action decided upon. This 'redefined' autonomy requires, not only the negative allowing of decision and action on the part of others emphasized by Brock, but also and primarily the positive support of others and their input into those three steps of autonomous decision-making, as Grace Clement speaks of. It is this concept of autonomy as intrinsically relational that allows us to focus, not on obeying or allowing a patient's wishes at all costs (such as euthanasia), but in fact commits us to respond to and to attempt to influence the process by which the patient arrives at his/her judgments. We see that the circumstances and opportunities open to a person are a significant part of the persons' life assessment, and that these circumstances and opportunities depend to a large extent on the social structures surrounding the patient and the messages coming from society, and most directly from one's caregivers. The best thing for caregivers to do is to focus on the intrinsic dignity of each patient and to help identify an array of opportunities available to each patient to exercise his/her autonomy and to grow in virtue. The feeling or sense that patients have over their own dignity relates more to how they perceive their losses and circumstances than to what those losses are. The patient's self-worth is not completely invulnerable to the loss of health. Both external goods, such as health and wealth, and relational goods influence the value judgment of a person and can, in fact, influence the very character of the person- positively or negatively. The ancient philosopher, Aristotle, says that 'eudemonia' or happiness is vulnerable to the great loss of external goods, such as in the case of a patient who has lost health to the point of being terminally ill. Yet, he also says that even in great loss, the "fineness shines through" in the person who is noble and magnanimous. Within the hierarchy of goods, Aristotle places the goods of the soul as higher than the goods of the body. Relational goods play an especially important role, and are also higher than the goods of the body. From this perspective, a terminally ill patient and his/her caregivers may be encouraged to place greater weight on relationships and virtue than on physiological limitations. In fact, the loss of health and function can be re-evaluated as precisely the needed opportunity to grow in certain context-dependent relational virtues. Within the appropriate circumstances, the patient will be more easily able to live more of 'the good life', and become, not less human through external loss, but rather more human through relational virtues. The new moral ideal becomes, not the atomistic-autonomous individual, but the interdependent-autonomous individual. Politically, socially, and personally, we would do better to promote this latter moral ideal by creating circumstances and opportunities for caregivers to respect the patients' autonomy and dignity in the positive sense.

Maternal-fetal conflicts, specifically court-ordered Cesarean sections, are explored from a legal and ethical perspective. An increase in technology, combined with the rise of bioethics, the respect for autonomy in medical decision-making, and the legal doctrine of informed consent have created an atmosphere in which conflicts may occur between the pregnant woman and her fetus. The scant legal precedent in this area does not provide a clear standard for evaluating cases in which a pregnant woman with a viable fetus refuses a recommended Cesarean section. The analysis first examines the clinical aspects of a Cesarean delivery, and then turns to a discussion of the legal precedent and the potentially analogous areas of law (i.e. abortion, parent-child relationships, and organ donation). In addition, there is an examination of the ethical and policy considerations, which weigh heavily in favor of honoring the pregnant womans wishes over the perceived benefit for the fetus. Finally, a judicial standard is proposed which combines the legal and ethical analyses, and concludes that a court should virtually never override a competent patients decision to refuse a Cesarean section.

Autonomy is a core value of American tradition and is promoted in health care through the doctrine of informed consent. The notion underlying informed consent is that patients should have the right to decide, and are often in the best position to know, what will enhance their own well-being. Although this ethic has been extended to incompetent patients, by employing surrogate decision making, providing surrogate decision makers for adults with moderate, mild, and borderline mental retardation (M-BMR), who could potentially make their own decisions if adequate supports were offered, unreasonably restricts the autonomy of such individuals and often results in disregard for the patients human dignity. This thesis recommends that health care institutions provide a personal assistant for all health care visits involving adults with M-BMR. In her role as an advocate for the patient, the personal assistant would offer a less restrictive means of promoting the patients autonomy in medical decision making than has limited guardianship, thus furthering the goals of guardianship reform that limited guardianship has been unable to do. Serving as an educator and translator, the personal assistant would provide a means to equalize the patients opportunity to understand the diagnosis, treatment options, and risks and benefits of those treatments. Alternatively, in cases where a surrogate decision maker is required, the personal assistant would aid in equalizing the patients opportunity to understand what is happening during medical procedures by ensuring continued communication with the patient with M-BMR. Finally, having training in ethics, the personal assistant would foster a collaborative approach to medical decision making that recognizes the importance of incorporating both the physicians experience and knowledge and the family member or caregivers unique understanding of the patient in the medical decision. Together, the personal assistant and the collaborative decision making approach will enhance discussion between the physician, patient, and family member or caregiver, thereby helping balance the autonomy and the well-being of the patient with M-BMR, while also ensuring that the patients dignity is respected.

This paper explores the syndrome of dementia and the way in which it affects a persons capacity to make a medical decision. The symptoms of dementia exist along a continuum, meaning that a patient will begin with a mild form of dementia and then progress to a more severe form of this syndrome. This paper argues that although demented patients generally do not have the capacity to make medical decisions, some demented patients, because of the continuum nature of the syndrome, can participate in the planning of their care and, in some cases, participate in the informed consent process. It maintains that the principles of respect for autonomy and dignity, beneficence, and justice provide ethical reasons for involving demented patients in the care when they are capable to do so. Moreover, this paper contends that ageism, sexism, and hypercognitivism are biases that likely affect the way in which physicians view their demented patients, and consequently, the intersectionality of these three biases may play a role in a physicians disregard for an elderly demented patients involvement in the planning of their care. Finally, the way in which physicians interpret the idea of involvement provides further reasons to explain why physicians sometimes exclude demented patients in participating in decisionmaking. This paper concludes by providing some suggestions for positively involving demented patients in care planning.

The concept of gene-environment interaction, or G×E, refers to cases where different genetic groups respond differently to the same array of environments for a particular phenotypic trait. In a widely acclaimed study from 2002, researchers found a case of G×E for a gene associated with neuroenzymatic activity (low vs. high), exposure to childhood maltreatment, and the development of antisocial personality disorder (ASPD), or sociopathy. Cases of G×E are generally characterized as evincing a genetic predisposition to the trait under consideration; for example, individuals with low neuroenzymatic activity are generally characterized as having a genetic predisposition to ASPD. Bioethical commentators in turn have asked: Should parents test their embryos or fetuses for this genetic predisposition to ASPD in order to screen against the gene associated with low-MAOA activity? Should the state test all newborns for this genetic predisposition to ASPD in order to identify and treat individuals with the gene associated with low-MAOA activity from birth? I first show that the concept of a genetic predisposition fundamentally misconstrues the ASPD study. That concept is appropriately applied only to cases of G×E that result in a change of scale, but the ASPD study resulted in a change of rank. For cases of G×E that result in a change of rank, I introduce a new conceptinteractive predisposition. Then, I show how this switch from a genetic predisposition to an interactive predisposition reconfigures old questions and raises new questions in the confines of the ethical discussions about the implications of such studies. For the ASPD study, attempts to screen against the gene associated with low-MAOA activity potentially fall prey to the myth of pre-environmental prediction, and attempts to screen all newborns for the gene associated with low-MAOA activity with an eye towards early intervention will have to face the interventionists dilemma. Moving beyond the ASPD study, traditional cost-benefit analyses involved in deciding whether or not to undertake the genetic testing of a child will have to be reweighed when the disease/disorder of concern results from an interactive predisposition rather than a genetic predisposition.

The Physician Orders for Life-Sustaining Treatment (POLST) is a novel end of life advance planning tool that is being authorized for use in many jurisdictions. In form, the POLST is similar to medical order sets that are routinely completed by doctors in hospitals and nursing homes to specify or limit life-sustaining treatments for patients who are near the end of their lives. However, the POLST is completed by a physician before the onset of a medical crisis, and can be used by patients to control end of life medical treatment like an instruction directive or prehospital Do-Not-Resuscitate (DNR) order. The POLST has some of the same weaknesses associated with instruction directives and DNR orders. There is a risk with the POLST that life-sustaining medical treatments will be forgone when the patient would have wanted them had he or she been able to communicate. A POLST may be incorrectly viewed by doctors as a general signal for limited treatment. There can be a lack of clarity regarding what specific procedures are covered by the POLST. It is unclear whether a physician may sign a POLST for a patient unilaterally, and whether a patient or surrogate may override the form without a physicians concurrence. The POLST has some unique weaknesses resulting from the requirement that it be transferable between treatment settings, and the fact it can co-exist with a conflicting instruction directive. All of the research studies that have been done on the POLST have significant methodological weaknesses. It is not reasonable to conclude from these studies that the POLST is more effective than instruction directives and prehospital DNR forms in allowing patients to control their end of life medical care. While the POLST is a useful addition to the tools that patients can use to control their end of life care, people may be led to believe that this advance planning device is more useful than it really is.

The present thesis poses a focused challenge to the abstinence-only approach in adolescent sex education. The first chapter clarifies the term abstinence-only and provides context to the debate surrounding the abstinence-only approach. The second chapter addresses at length the role of information provision in the development of knowledge and decisional skills in adolescents. Abstinence-only education is indefensible because of its refusal to provide a significant measure of sexual health information to adolescents, even though these individuals are, by and large, capable of understanding and reflecting upon such information. Furthermore, exposure to accurate, relevant, and comprehensive information is crucial to the strengthening of adolescents emergent decisional capacities. Thus the provision of information lends itself greatly to adolescents maturation as reliable decision-makers. In the third chapter, I maintain that the abstinence-only approach fails to recognize the value of providing students with an appropriate discursive venue in which they may meaningfully discuss their own perspectives while also developing a sense of the views and needs of other sexual citizens. The pro-discourse stance I take in this chapter responds to the charges of discourse opponents and demonstrates that these measures of censorship both passively waste opportunities for students to become well-informed, enabled, and empowered sexual agents and may actively damage and deprive the well-being and flourishing of particular groups.

The rise in prominence of public apologies since the mid 1990s and increased awareness of the frequency and severity of medical errors in the United States has led to scholarly and professional interest in doctors apologies in response to medical error. Literature targeting health care professionals indicates a growing consensus about the ethical and professional imperatives for apology. However, it also exposes the authors difficulty in achieving conceptual clarity about apology and its application to modern clinical practice carried out by multiple providers within complex medical, legal, and insurance systems. This project articulates the ethical underpinnings of apology and establishes ethically and professionally appropriate responses--both by clinicians and administrators of health care institutions--to medical error. Foundationally, this argument includes clarifying salient distinctions related to medical error and adverse events and conceptualizing apology as it is applicable to health care contexts. In sum, a policy or culture of responsibility--to which apology may instrumentally contribute--is ethically valuable and contributes to overall quality of care in contemporary health care institutions. The roles and responsibilities of clinicians and administrators within a culture of responsibility are discussed, in addition to the structure, applications, limitations, and ethical considerations of policies regarding apology.

The current thesis poses a focused critique and ethical analysis of medical brigades as they currently operate in Honduras. The first chapter defines the concept of medical brigades and provides an account of their presence and actions within Honduras. The second chapter addresses the need for a theoretical framework with which to ethically analyze the endeavors of these brigades. Due to an insufficient amount of attention and scrutiny, no authoritative standard yet exists for evaluating the ethics of developed countries providing health care interventions in developing countries. In order to overcome this challenge, the current thesis creates a hybrid framework by looking to established codes of conduct from several pre-existing models of engagement with potentially vulnerable populations, all of which have already addressed some pertinent aspect of medical brigades. Through examining the principles, ethics and relevance of the doctor-patient relationship, Standard of Care debates and Community-Based Participatory Research, this thesis places certain obligations on medical brigade participants and their affiliated organizations, which must to be fulfilled in order for their actions to be considered ethical. In the third chapter, I maintain that medical brigades fail to fulfill these obligations based on the harms they pose to the communities and community members they serve. Fundamentally, these brigades pose a risk because of their short-term nature that does not provide accountability or follow-up care, nor addresses community-relevant health care needs. Finally, the fourth chapter demonstrates the ways in which the developed world can improve upon this model and carry out ethical health care interventions in the developing world, specifically by avoiding these harms and fulfilling the aforementioned obligations. To facilitate this discussion, I will present the Shoulder to Shoulder model, the Community-Oriented Primary Care model and SEED-SCALE as ethical alternatives to the medical brigade model. These examples collectively provide a solid platform on which to base a much needed change in the current medical brigade model, and a bright future for the direction of health care provided by volunteers in developing countries.