Theodore Fleischer - Academia.edu (original) (raw)

Papers by Theodore Fleischer

Santa Clara law review, 1963

Hastings Center Report, Sep 1, 2006

PubMed, Jun 1, 2007

During the twentieth century, spectacular developments in science, technology and medical practic... more During the twentieth century, spectacular developments in science, technology and medical practice coupled with economic growth have transformed health care and improved the lives of many people. Despite such progress, the world today is more inequitable than it was 50 years ago: disparities in wealth and health are widening inexorably, and infectious diseases are again becoming a major scourge and pose a threat to the lives of all. Hundreds of millions of people live in degrading poverty, with little, if any, access to health care. Recognition of this context in which much research takes place should sharpen our focus on the ethical requirements for research that could improve the health of a greater proportion of the world's population--one of the most pressing moral problems of our time. The intense debate on ethical dilemmas associated with an expanding programme of clinical research in developing countries has revealed much common ground, but has also left a residuum of controversy. We suggest that contested issues could be resolved by paying greater attention to different world views on the relationship between research and clinical care and by defining policies that both progressively improve the standard of care in research and link research to improved delivery of health care in developing countries.

Continuing Medical Education, 2003

Perspectives in Biology and Medicine, 2001

Perspectives in Biology and Medicine, 1999

Along with other thoughtful people through the ages, Jewish and Christian communities have long w... more Along with other thoughtful people through the ages, Jewish and Christian communities have long wrestled with the mystery of suffering. Although many solutions have been offered, no definitive answers have been recognized by either community. While these ancient traditions persist in their search to understand the moral and spiritual meaning of suffering, 20th-century medicine conceptualizes the enigma of suffering as primarily a technical, rather than a moral or a spiritual, problem. We ask why doctors fail to give adequate pain relief, but not how patients can shape a response to their suffering. The culmination of this approach is, in one sense, the heated debate over physician-assisted suicide. Through physician-assisted suicide, medical technology makes good on its promise to eradicate suffering, even if this means eradicating the sufferer. Much recent analysis of palliative care and physician-assisted suicide has focused on narrowly framed moral and legal issues. We pay less attention to questions about the meaning of intractable suffering. Instead we act as if suffering has no meaning, or as if it is an unambiguous and unalloyed evil, more to be feared than death itself. When medicine, health law, and bioethics take this approach, they ignore thousands of years of effort by philosophers, theologians, and writers to uncover the meaning of human suffering. We learn something about the moral dimensions of human suffering in Tithe Olsen's haunting story, "Tell Me a Riddle" [I]. In the story, Evaa bitter old woman-is dying of cancer. She has become estranged from David, her husband of 47 years. It seems impossible that anything good can emerge from her horrible suffering. Yet in her last days, Eva gathers her memories of childhood in Russia and celebrates long-forgotten ideological The author wishes to thank Carl Elliott and John Lantos for invaluable suggestions that significantly crystallized and refined the ideas and themes.

JAMA, May 23, 2007

Dreaming of a global bioethics? The day when bioethics will bequeath to the world a universally a... more Dreaming of a global bioethics? The day when bioethics will bequeath to the world a universally applicable set of moral norms that will transcend cultural and religious diversity and lead to fair, rational resolutions to bioethical dilemmas everywhere? Dream on, say the contributors to this intriguing collection of essays. We are standing in the "ruins of attempts at global bioethics" (p vii).

PubMed, Jun 1, 2003

One hallmark of modern medicine is the ever-rising cost of providing life-saving or life-extendin... more One hallmark of modern medicine is the ever-rising cost of providing life-saving or life-extending treatments. Advances in medical care and the ability to improve the duration and quality of life, combined with the expectations of both doctors and patients that all new modalities of treatment developed will be implemented in everyday practice, are the major reasons for modern medicine's becoming so expensive. In these circumstances resource allocation decisions need to be made and appropriate priority-setting processes developed. This challenge faces all societies but most agonisingly middleincome countries like South Africa where the expectations of physicians and patients are geared to the best that can be achieved in any country-even the wealthiest.

Global Public Health, May 1, 2013

The escalating expenditure on patients with HIV/AIDS within an inadequately funded public health ... more The escalating expenditure on patients with HIV/AIDS within an inadequately funded public health system is tending towards crowding out care for patients with non-HIV illnesses. Priority-setting decisions are thus required and should increasingly be based on an explicit, transparent and accountable process to facilitate sustainability. South Africa's public health system is eroding, even though the government has received extensive donor financing for specific conditions, such as HIV/AIDS. The South African government's 2007 HIV plan anticipated costs exceeding 20% of the annual health budget with a strong focus on treatment interventions, while the recently announced 2012-2016 National Strategic HIV plan could cost up to US$16 billion. Conversely, the total non-HIV health budget has remained static in recent years, effectively reducing the supply of health care for other diseases. While the South African government cannot meet all demands for health care simultaneously, health funders should attempt to allocate health resources in a fair, efficient, transparent and accountable manner, in order to ensure that publicly funded health care is delivered in a reasonable and non-discriminatory fashion. We recommend a process for resource allocation that includes ethical, economic, legal and policy considerations. This process, adapted for use by South Africa's policy-makers, could bring health, political, economic and ethical gains, whilst allaying a social crisis as mounting treatment commitments generated by HIV have the potential to overwhelm the health system.

Interventional Neuroradiology, Dec 1, 2003

This argument may not seem compelling or relevant to interventionists focused on providing highly... more This argument may not seem compelling or relevant to interventionists focused on providing highly specialized care to individuals afflicted by a narrow band of diseases, such as vascular disease. However, doctors must recognize that no effort to rationally and fairly dis-An alternative view is that interventionists have a moral obligation to help improve the

PubMed, Aug 1, 2000

C Peter, A Pope, A TaylorWhereas in the past lack of knowledge and lack ofappropriatetechnology p... more C Peter, A Pope, A TaylorWhereas in the past lack of knowledge and lack ofappropriatetechnology prevented doctors from being able to save andextend life in many fields ofmedical care, today knowledgeabounds and access to appropriate technology is increasinglypossible. The difficulty is that lack of financial resourcesprevents doctors from applying modem medical knowledgeuniversally, to the benefit ofall patients.Even in the USA, where the annual per capita expenditureon health care is in excess ofUS$4 000, it is not possible toprovide every citizen with all that medicine can offer. Theproblem ofscarce resources is indeed pervasive and affects allcountries. As a result, resource allocation considerations, lesspopularly called 'rationing',have become a major topic ofdebate throughout the world.'In this article we wish to review the current situationregarding the treatment of severe head injuries in adults atGroote Schuur Hospital (GSH). We do so not as a plea for moreresources, but rather to highlight the challenges facingacademic institutions in SouthAfrica and to illustrate the needfor open public debate and explicit rationing in relation to thisand other vexing clinical problems in our institution.There is an undisputed need in South Africa to avoidincreasing the national debt, to allocate resources more fairlyacross the country and to improve access to health care at theprimary care level. It is also appropriate that the public knowabout and understand the impact ofsuch reallocation on thehealth care services they can expect to receive within ourtertiary academic institutions.'"'InSouthAfrica the problem of resource allocation within thepublic sector is particularly acute. The reasons for this include:

The international journal of tuberculosis and lung disease : the official journal of the International Union against Tuberculosis and Lung Disease, 2007

During the twentieth century, spectacular developments in science, technology and medical practic... more During the twentieth century, spectacular developments in science, technology and medical practice coupled with economic growth have transformed health care and improved the lives of many people. Despite such progress, the world today is more inequitable than it was 50 years ago: disparities in wealth and health are widening inexorably, and infectious diseases are again becoming a major scourge and pose a threat to the lives of all. Hundreds of millions of people live in degrading poverty, with little, if any, access to health care. Recognition of this context in which much research takes place should sharpen our focus on the ethical requirements for research that could improve the health of a greater proportion of the world's population--one of the most pressing moral problems of our time. The intense debate on ethical dilemmas associated with an expanding programme of clinical research in developing countries has revealed much common ground, but has also left a residuum of con...

JAMA: The Journal of the American Medical Association, 1998

When I began this book during the hopeful days of 1994, there was every expectation that the Unit... more When I began this book during the hopeful days of 1994, there was every expectation that the United States would imminently have a universal health insurance plan. How could it be otherwise? Everyone seemed to want one, and with good reason. Some 37 million people ...

The Hastings Center Report, 2000

South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde, 2003

One hallmark of modern medicine is the ever-rising cost of providing life-saving or life-extendin... more One hallmark of modern medicine is the ever-rising cost of providing life-saving or life-extending treatments. Advances in medical care and the ability to improve the duration and quality of life, combined with the expectations of both doctors and patients that all new modalities of treatment developed will be implemented in everyday practice, are the major reasons for modern medicine's becoming so expensive. In these circumstances resource allocation decisions need to be made and appropriate priority-setting processes developed. This challenge faces all societies but most agonisingly middle-income countries like South Africa where the expectations of physicians and patients are geared to the best that can be achieved in any country — even the wealthiest. Expensive, new or established standard treatments that may benefit patients may be considered in at least two categories. The first is when each individual patient will be a direct beneficiary. This applies, for example, when a...

South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde, 2000

C Peter, A Pope, A TaylorWhereas in the past lack of knowledge and lack ofappropriatetechnology p... more C Peter, A Pope, A TaylorWhereas in the past lack of knowledge and lack ofappropriatetechnology prevented doctors from being able to save andextend life in many fields ofmedical care, today knowledgeabounds and access to appropriate technology is increasinglypossible. The difficulty is that lack of financial resourcesprevents doctors from applying modem medical knowledgeuniversally, to the benefit ofall patients.Even in the USA, where the annual per capita expenditureon health care is in excess ofUS$4 000, it is not possible toprovide every citizen with all that medicine can offer. Theproblem ofscarce resources is indeed pervasive and affects allcountries. As a result, resource allocation considerations, lesspopularly called 'rationing',have become a major topic ofdebate throughout the world.'In this article we wish to review the current situationregarding the treatment of severe head injuries in adults atGroote Schuur Hospital (GSH). We do so not as a plea for moreresources, but rather to highlight the challenges facingacademic institutions in SouthAfrica and to illustrate the needfor open public debate and explicit rationing in relation to thisand other vexing clinical problems in our institution.There is an undisputed need in South Africa to avoidincreasing the national debt, to allocate resources more fairlyacross the country and to improve access to health care at theprimary care level. It is also appropriate that the public knowabout and understand the impact ofsuch reallocation on thehealth care services they can expect to receive within ourtertiary academic institutions.'"'InSouthAfrica the problem of resource allocation within thepublic sector is particularly acute. The reasons for this include:

JAMA: The Journal of the American Medical Association, 1999

JAMA, 2007

Dreaming of a global bioethics? The day when bioethics will bequeath to the world a universally a... more Dreaming of a global bioethics? The day when bioethics will bequeath to the world a universally applicable set of moral norms that will transcend cultural and religious diversity and lead to fair, rational resolutions to bioethical dilemmas everywhere? Dream on, say the contributors to this intriguing collection of essays. We are standing in the "ruins of attempts at global bioethics" (p vii).

Santa Clara law review, 1963

Santa Clara law review, 1963

Hastings Center Report, Sep 1, 2006

PubMed, Jun 1, 2007

During the twentieth century, spectacular developments in science, technology and medical practic... more During the twentieth century, spectacular developments in science, technology and medical practice coupled with economic growth have transformed health care and improved the lives of many people. Despite such progress, the world today is more inequitable than it was 50 years ago: disparities in wealth and health are widening inexorably, and infectious diseases are again becoming a major scourge and pose a threat to the lives of all. Hundreds of millions of people live in degrading poverty, with little, if any, access to health care. Recognition of this context in which much research takes place should sharpen our focus on the ethical requirements for research that could improve the health of a greater proportion of the world's population--one of the most pressing moral problems of our time. The intense debate on ethical dilemmas associated with an expanding programme of clinical research in developing countries has revealed much common ground, but has also left a residuum of controversy. We suggest that contested issues could be resolved by paying greater attention to different world views on the relationship between research and clinical care and by defining policies that both progressively improve the standard of care in research and link research to improved delivery of health care in developing countries.

Continuing Medical Education, 2003

Perspectives in Biology and Medicine, 2001

Perspectives in Biology and Medicine, 1999

Along with other thoughtful people through the ages, Jewish and Christian communities have long w... more Along with other thoughtful people through the ages, Jewish and Christian communities have long wrestled with the mystery of suffering. Although many solutions have been offered, no definitive answers have been recognized by either community. While these ancient traditions persist in their search to understand the moral and spiritual meaning of suffering, 20th-century medicine conceptualizes the enigma of suffering as primarily a technical, rather than a moral or a spiritual, problem. We ask why doctors fail to give adequate pain relief, but not how patients can shape a response to their suffering. The culmination of this approach is, in one sense, the heated debate over physician-assisted suicide. Through physician-assisted suicide, medical technology makes good on its promise to eradicate suffering, even if this means eradicating the sufferer. Much recent analysis of palliative care and physician-assisted suicide has focused on narrowly framed moral and legal issues. We pay less attention to questions about the meaning of intractable suffering. Instead we act as if suffering has no meaning, or as if it is an unambiguous and unalloyed evil, more to be feared than death itself. When medicine, health law, and bioethics take this approach, they ignore thousands of years of effort by philosophers, theologians, and writers to uncover the meaning of human suffering. We learn something about the moral dimensions of human suffering in Tithe Olsen's haunting story, "Tell Me a Riddle" [I]. In the story, Evaa bitter old woman-is dying of cancer. She has become estranged from David, her husband of 47 years. It seems impossible that anything good can emerge from her horrible suffering. Yet in her last days, Eva gathers her memories of childhood in Russia and celebrates long-forgotten ideological The author wishes to thank Carl Elliott and John Lantos for invaluable suggestions that significantly crystallized and refined the ideas and themes.

JAMA, May 23, 2007

Dreaming of a global bioethics? The day when bioethics will bequeath to the world a universally a... more Dreaming of a global bioethics? The day when bioethics will bequeath to the world a universally applicable set of moral norms that will transcend cultural and religious diversity and lead to fair, rational resolutions to bioethical dilemmas everywhere? Dream on, say the contributors to this intriguing collection of essays. We are standing in the "ruins of attempts at global bioethics" (p vii).

PubMed, Jun 1, 2003

One hallmark of modern medicine is the ever-rising cost of providing life-saving or life-extendin... more One hallmark of modern medicine is the ever-rising cost of providing life-saving or life-extending treatments. Advances in medical care and the ability to improve the duration and quality of life, combined with the expectations of both doctors and patients that all new modalities of treatment developed will be implemented in everyday practice, are the major reasons for modern medicine's becoming so expensive. In these circumstances resource allocation decisions need to be made and appropriate priority-setting processes developed. This challenge faces all societies but most agonisingly middleincome countries like South Africa where the expectations of physicians and patients are geared to the best that can be achieved in any country-even the wealthiest.

Global Public Health, May 1, 2013

The escalating expenditure on patients with HIV/AIDS within an inadequately funded public health ... more The escalating expenditure on patients with HIV/AIDS within an inadequately funded public health system is tending towards crowding out care for patients with non-HIV illnesses. Priority-setting decisions are thus required and should increasingly be based on an explicit, transparent and accountable process to facilitate sustainability. South Africa's public health system is eroding, even though the government has received extensive donor financing for specific conditions, such as HIV/AIDS. The South African government's 2007 HIV plan anticipated costs exceeding 20% of the annual health budget with a strong focus on treatment interventions, while the recently announced 2012-2016 National Strategic HIV plan could cost up to US$16 billion. Conversely, the total non-HIV health budget has remained static in recent years, effectively reducing the supply of health care for other diseases. While the South African government cannot meet all demands for health care simultaneously, health funders should attempt to allocate health resources in a fair, efficient, transparent and accountable manner, in order to ensure that publicly funded health care is delivered in a reasonable and non-discriminatory fashion. We recommend a process for resource allocation that includes ethical, economic, legal and policy considerations. This process, adapted for use by South Africa's policy-makers, could bring health, political, economic and ethical gains, whilst allaying a social crisis as mounting treatment commitments generated by HIV have the potential to overwhelm the health system.

Interventional Neuroradiology, Dec 1, 2003

This argument may not seem compelling or relevant to interventionists focused on providing highly... more This argument may not seem compelling or relevant to interventionists focused on providing highly specialized care to individuals afflicted by a narrow band of diseases, such as vascular disease. However, doctors must recognize that no effort to rationally and fairly dis-An alternative view is that interventionists have a moral obligation to help improve the

PubMed, Aug 1, 2000

C Peter, A Pope, A TaylorWhereas in the past lack of knowledge and lack ofappropriatetechnology p... more C Peter, A Pope, A TaylorWhereas in the past lack of knowledge and lack ofappropriatetechnology prevented doctors from being able to save andextend life in many fields ofmedical care, today knowledgeabounds and access to appropriate technology is increasinglypossible. The difficulty is that lack of financial resourcesprevents doctors from applying modem medical knowledgeuniversally, to the benefit ofall patients.Even in the USA, where the annual per capita expenditureon health care is in excess ofUS$4 000, it is not possible toprovide every citizen with all that medicine can offer. Theproblem ofscarce resources is indeed pervasive and affects allcountries. As a result, resource allocation considerations, lesspopularly called 'rationing',have become a major topic ofdebate throughout the world.'In this article we wish to review the current situationregarding the treatment of severe head injuries in adults atGroote Schuur Hospital (GSH). We do so not as a plea for moreresources, but rather to highlight the challenges facingacademic institutions in SouthAfrica and to illustrate the needfor open public debate and explicit rationing in relation to thisand other vexing clinical problems in our institution.There is an undisputed need in South Africa to avoidincreasing the national debt, to allocate resources more fairlyacross the country and to improve access to health care at theprimary care level. It is also appropriate that the public knowabout and understand the impact ofsuch reallocation on thehealth care services they can expect to receive within ourtertiary academic institutions.'"'InSouthAfrica the problem of resource allocation within thepublic sector is particularly acute. The reasons for this include:

The international journal of tuberculosis and lung disease : the official journal of the International Union against Tuberculosis and Lung Disease, 2007

During the twentieth century, spectacular developments in science, technology and medical practic... more During the twentieth century, spectacular developments in science, technology and medical practice coupled with economic growth have transformed health care and improved the lives of many people. Despite such progress, the world today is more inequitable than it was 50 years ago: disparities in wealth and health are widening inexorably, and infectious diseases are again becoming a major scourge and pose a threat to the lives of all. Hundreds of millions of people live in degrading poverty, with little, if any, access to health care. Recognition of this context in which much research takes place should sharpen our focus on the ethical requirements for research that could improve the health of a greater proportion of the world's population--one of the most pressing moral problems of our time. The intense debate on ethical dilemmas associated with an expanding programme of clinical research in developing countries has revealed much common ground, but has also left a residuum of con...

JAMA: The Journal of the American Medical Association, 1998

When I began this book during the hopeful days of 1994, there was every expectation that the Unit... more When I began this book during the hopeful days of 1994, there was every expectation that the United States would imminently have a universal health insurance plan. How could it be otherwise? Everyone seemed to want one, and with good reason. Some 37 million people ...

The Hastings Center Report, 2000

South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde, 2003

One hallmark of modern medicine is the ever-rising cost of providing life-saving or life-extendin... more One hallmark of modern medicine is the ever-rising cost of providing life-saving or life-extending treatments. Advances in medical care and the ability to improve the duration and quality of life, combined with the expectations of both doctors and patients that all new modalities of treatment developed will be implemented in everyday practice, are the major reasons for modern medicine's becoming so expensive. In these circumstances resource allocation decisions need to be made and appropriate priority-setting processes developed. This challenge faces all societies but most agonisingly middle-income countries like South Africa where the expectations of physicians and patients are geared to the best that can be achieved in any country — even the wealthiest. Expensive, new or established standard treatments that may benefit patients may be considered in at least two categories. The first is when each individual patient will be a direct beneficiary. This applies, for example, when a...

South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde, 2000

C Peter, A Pope, A TaylorWhereas in the past lack of knowledge and lack ofappropriatetechnology p... more C Peter, A Pope, A TaylorWhereas in the past lack of knowledge and lack ofappropriatetechnology prevented doctors from being able to save andextend life in many fields ofmedical care, today knowledgeabounds and access to appropriate technology is increasinglypossible. The difficulty is that lack of financial resourcesprevents doctors from applying modem medical knowledgeuniversally, to the benefit ofall patients.Even in the USA, where the annual per capita expenditureon health care is in excess ofUS$4 000, it is not possible toprovide every citizen with all that medicine can offer. Theproblem ofscarce resources is indeed pervasive and affects allcountries. As a result, resource allocation considerations, lesspopularly called 'rationing',have become a major topic ofdebate throughout the world.'In this article we wish to review the current situationregarding the treatment of severe head injuries in adults atGroote Schuur Hospital (GSH). We do so not as a plea for moreresources, but rather to highlight the challenges facingacademic institutions in SouthAfrica and to illustrate the needfor open public debate and explicit rationing in relation to thisand other vexing clinical problems in our institution.There is an undisputed need in South Africa to avoidincreasing the national debt, to allocate resources more fairlyacross the country and to improve access to health care at theprimary care level. It is also appropriate that the public knowabout and understand the impact ofsuch reallocation on thehealth care services they can expect to receive within ourtertiary academic institutions.'"'InSouthAfrica the problem of resource allocation within thepublic sector is particularly acute. The reasons for this include:

JAMA: The Journal of the American Medical Association, 1999

JAMA, 2007

Dreaming of a global bioethics? The day when bioethics will bequeath to the world a universally a... more Dreaming of a global bioethics? The day when bioethics will bequeath to the world a universally applicable set of moral norms that will transcend cultural and religious diversity and lead to fair, rational resolutions to bioethical dilemmas everywhere? Dream on, say the contributors to this intriguing collection of essays. We are standing in the "ruins of attempts at global bioethics" (p vii).

Santa Clara law review, 1963