Global Health Challenges: The Need for an Expanded Discourse on Bioethics

Benatar and colleagues argue that the world has changed profoundly since the birth of modern bioethics in the 1960s, and that bioethics needs to address today's global health problems

Global health challenges: The need for an expanded discourse on bioethics

Although the 20th century saw a major expansion of the world economy, impressive military/security advances, and spectacular progress in science and technology, the grim reality in the first decade of the new millennium is that human life, health, and security remain under severe threat—but now from the adverse effects of inexorably widening disparities in wealth, health, and knowledge within and between nations. The gap between the income of the richest and poorest 20% of people in the world increased from a 9-fold difference at the beginning of the 20th century to 30-fold by 1960—and since then to over 80-fold by 2000 (Figure 1). Although life expectancy has improved dramatically worldwide during this century, this trend has been reversed in the poorest countries in recent years [1]. The challenge of achieving improved health for a greater proportion of the world's population is one of the most pressing problems of our time and is starkly illustrated by the threat of infectious diseases

Patients with severe mental illness: A new approach to testing for HIV

Background. The prevalence of HIV infection in South Africa is approaching 20% of young adults. In severely mentally ill people it is probably higher. Testing for infection is subject to stringent ethical principles. Undiagnosed HIV infection in people with severe mental illness increases costs and morbidity. Since effective treatments are available, it is imperative to diagnose HIV infection early in this high-risk population. Methods. A literature review established the prevalence of HIV infection in inpatient populations with HIV infection. The pattern of testing for HIV over 3 years at a major psychiatric hospital was investigated. We surveyed public sector psychiatrists in the Western Cape to establish their attitudes to HIV in their patients. Results. The reported HIV seroprevalence in psychiatric inpatients ranges from 0 to 59.3%, with a mean of 10%. Data show a clear trend towards an increase in prevalence: before 1996 the mean HIV seroprevalence was 7.4%, while after 1996 the mean was 15%. State psychiatrists in the Western Cape do not test routinely for HIV infection, mainly owing to ethical constraints: 14.6% of patients at Lentegeur Hospital were tested in 2006. Conclusions. The high prevalence of HIV infection in South Africa, which is probably higher in patients with severe mental illness (most of whom are not competent to provide informed consent), and the availability of effective treatment require debate and a clear policy regarding testing for HIV infection to be implemented. We recommend a new approach to HIV testing in these patients. South African Medical Journal Vol. 98 (3) 2008: pp. 213-21

Informed consent - a survey of doctors' practices in South Africa

Objective. To examine doctors' practices with regard to informed consent.Design. Cross-sectional, descriptive survey.Participants 'and setting. All full-time consultants and registrars in the Departments of Medicine, Obstetrics and Gynaecology, Paediatrics and Child Health, Paediatric Surgery and Surgery at the University of Cape Town were included. The overall response rate was 63% (160/254).Measurement. Data were collected by means of selfadministered, semi-structured questionnaires.Results. Most doctors (79%) felt it was their responsibility to ensure that patients and parents were fully informed about diagnostic and therapeutic interventions. Many (62%) supported a patient-centred standard for determining the type and amount of information to disclose. Doctors disclose most of the legally required information except for information about alternative forms of treatment and remote serious risks. They almost never provide information on medical costs. The most common reasons for not obtaining informed consent were the doctors' tendency to 'tell' patients! parents what they intend doing and their belief that patients/parents expect doctors to know what is medicallybest for them. Language, inadequate communication skills and lack of time were, surprisingly, seldom viewed as obstacles to the obtaining of informed consent. Findings were independent of discipline (medical or surgical) and doctors' status (consultant or registrar). Doctors who treat children were significantly less likely to obtain consent forcertain interventions.Conclusion. Doctors meet many, but not all, of the legal requirements for informed consent. The findings question whether informed consent as envisioned by the law existsin reality. Cross-cultural research is needed to clarify patients' and parents' expectations of informed consent

The hypothetical consent objection to anti-natalism

Abstract: A very common but untested assumption is that potential children would consent to be exposed to the harms of existence in order to experience its benefits (if it were possible for us to ask and for them to respond). And so, would-be parents might appeal to the following view: Procreation is all-things-considered permissible, as it is morally acceptable for one to knowingly harm an unconsenting patient if one has good reasons for assuming her hypothetical consent—and procreators can indeed reasonably rely on some notion of hypothetical consent. I argue that this view is in error. My argument appeals to a consent-based version of anti-natalism advanced by Seana Valentine Shiffrin. Anti-natalism is the view that it is (almost) always wrong to bring people (and perhaps all sentient beings) into existence. While, like Shiffrin, I stop short of advocating a thoroughgoing anti-natalism, I nevertheless argue that procreators cannot appeal to hypothetical consent to justify exposing children to the harms of existence. I end by suggesting a more promising route by which this justification might be achieved

Clinical ethics revisited: responses

This series of responses was commissioned to accompany the article by Singer et al, which can be found at . If you would like to comment on the article by Singer et al or any of the responses, please email us on [email protected]