Browsing by Author "Howarth, Graham Robert"

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    The tyranny of a kilogram : should we untie rather than cut the Gordian knot?
    (Stellenbosch : Stellenbosch University, 1999-12) Howarth, Graham Robert; Van Niekerk, Anton A.; Stellenbosch University. Faculty of Medicine and Health Sciences. Centre for Medical Ethics and Law.
    ENGLISH ABSTRACT: The number of babies requiring neonatal intensive care exceeds the facilities available. The assignment questions the perceived shortage of resources and investigates methods of resource allocation. The first chapter addresses the development of technology and reflects briefly on the romance between medicine and technology. The second chapter addresses the issue of prognosis of the small preterm neonate and reflects on how these data are derived and the assumptions that are often made based on prognostic data. Chapter three concentrates on how outcomes discussed in the second chapter may be quantified. Individual utility quantification plays a role in decision making for the individual neonate, while comparative utility quantification addresses some of the issues concerned with the macroallocation of resources. This leads into chapter four that addresses macroallocation and challenges some of the assumptions that resource allocation is based upon. Are resources scarce? Are there financial constraints? What is the role of medicine in health? Will redistribution of wealth necessarily improve the health of the population? Who should. make decisions for individual sick neonates regarding neonatal intensive care is addressed in the next chapter. The tension between sanctity-of-life and quality-of-life ideologies, created by life sustaining technology has been legally and ethically settled in favour of the patient's right to self-determination, based on the principle of respect for patient autonomy. It will however be argued that the traditional four principles cannot be utilised as the neonate is at best pre-autonomous. Moral obligations towards the neonate are dependent on the beneficence and non-maleficence obligations of the parents and the caregivers. Both these principles are prima facie and may have to be tempered by distributive justice. Plato's absolutist thinking and Descartes mathematician's perspective, have influenced medicine's romance with certainty. If knowledge and certainty are necessary for decision· making and it is shown that absolute certainty is elusive, should we be nihilistic about decision making in neonatal intensive care? Chapter 6 critically assesses three approaches to decision making in the presence of prognostic uncertainty. In contemporary medicine there is a constant tension between the traditional commitment to the patient on the one hand and the awareness that resources are finite on the other, this tension is an unfortunate reality of medicine. To constrain the growth of medical expenditure, doctors are now asked to serve simultaneously as society's agent of cost containment and as the patient's agent for maximum health. There is increasing pressure on doctors to serve two masters, society and the patient. Acting on behalf of society as a gatekeeper, while for the patient the doctor is expected to act as advocate. Chapter seven investigates both gate-keeping and advocacy and attempts to answer the question whether doctors can and indeed should try to serve two masters Simultaneously? The final chapter brings together the threads of the various extended arguments and attempts to give solutions to some of the conundrums.