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She admits that there are diYculties in attempt- ing to deWne a ‘minimally satisfying life’: Conceptions of a minimally satisfying life vary tremendously among societies and within them buy generic precose 25mg online. De rigueur in some circles are private music lessons and trips to Europe buy precose 25 mg low cost, whereas in others providing eight years of schooling is a major accomplishment. But there is no need to consider this complication at length here because we are concerned only with health as a prerequisite for a minimally satisfying life. While this may be regarded as an unsatisfactory criterion in that in some cultures debilitating conditions may be the norm, Purdy suggests that this objection can be circumvented by saying that parents ought to try to provide for their children health that is normal for that culture, even though it may be inadequate if judged by some outside standard. She states that such a position would still justify eVorts to avoid the birth of children at risk for Huntington’s disease and other serious genetic diseases in all societies (Purdy, 1996: p. If the couple at risk of bearing a severely handicapped child make the decision to go ahead, then who precisely will bear the cost of care and of medical treatment if the risks attendant upon handicap materialize? The ‘welfare’ mother may decide to go ahead and have a child, but the consequent costs of bringing the child into the world are likely to fall upon the State in such a situation – housing, medical treatment and the fact that the woman may be unable to enter the workforce, at least for some time, due to child-care commitments. While some ‘harms’ and some ‘costs’ may be identiWed, does this lead us inexorably to the conclusion that persons should be held to be under a duty not to reproduce? Some may think that conception and birth where there is a risk of those harms/costs arising may be undesirable, but does this ever really equate with imposing a duty not to reproduce, and in particular, backing that duty up through some recognition of legal liability? First, he suggests that few of those conditions would make the life of a child so horrible that its interests would have been better served had that child never been born. Secondly, Robertson argues that because a woman’s reproductive interest is generally very strong, there would need to be compelling criteria to override it, and factors such as saving money would not generally be adequate. She suggests that there are other ways in which reproduc- tive desires may be satisWed, including adoption and the use of new reproduc- tive technologies. She comments that other arguments for having children, such as wanting the genetic line to be continued, are not particularly rational when it brings a sinister legacy of illness and death. She also states that while a desire to bear children who physically resemble oneself is understandable although basically narcissistic, its fulWlment cannot be guaranteed even by normal reproduction. It could be argued, however, that some of those persons whose opportunity to conceive naturally was, prima facie, limited by a duty not to reproduce, could still conceive through the use of artiWcial reproduc- tive technologies. One alternative is to say to such a couple, ‘You will be penalized if you reproduce naturally and the ‘‘harm’’ in the form of the disability materializes. However, you do have the option of pre-implantation genetic diagnosis, and this oVers you an alterna- tive; therefore we are not limiting your reproductive choices, your pro- creative liberty, to any great extent at all. Before we go down this road we need to address serious and fundamental questions, not simply about an individual’s choice, but also about society’s attitude to the disabled members of our community. Furthermore, the recognition of a duty not to reproduce may be regarded as unacceptable because it may mean that a person will in eVect be virtually forced to discover their genetic status should they want to reproduce. This may itself have other consequences with regards to the use of that genetic information – for example, with regards to insurance and employment prospects in years to come. It is worth noting that the Council of Europe (1996), in the Convention for the Protection of Human Rights and Dignity of the Human Being with Regard to the Application of Biology and Medicine, provides that: Everyone is entitled to know any information collected about his or her health. Say that there are certain, perhaps very limited, situations in which individuals may be wrong in seeking to reproduce – so wrong that they should actually be held to be under a duty. If the bodily intrusion associated with compulsory contraception is relatively minor, it may be that compelled contraception in rare cases could be justiWed, though such policies would be highly controversial. Some would argue that the a moral duty may be recognizable, but as Robertson has noted, that ‘does not mean that those duties should have legal standing’ (Robertson, 1994: p. To hold a woman or a couple liable for their decision to have a child, despite what are substantial warnings regarding the risks of such a course of action, might also constitute a breach of the European Convention on Human Rights – for example, of Article 12, the right to marry and found a family. There are fundamental questions regarding the privacy of the individual in relation to their home and family life under Article 8 which would arise in such a situation. It should also be noted that the Council of Europe Convention on Human Rights and Biomedicine provides in Article 11 that ‘Any form of non-discrimination against a person on grounds of his or her genetic heritage is prohibited’. We need of course to bear this in mind, particularly in view of the fact that those provisions of the European Convention of Human Rights are now justiciable in the English courts since the Human Rights Act 1988 came into force in October 2000. Secondly, would this be a duty involving state sanctions, enforceable, for example, through the criminal law or will it be limited to civil liability, perhaps in the form of an action brought by the child consequent upon birth? How do you inform people that they are under such a legal duty, and that if they reproduce without Wnding out their genetic status, there may be legal consequences? Do we have to put up notices in railway stations, general medical practitioners’ surgeries and night clubs warning people that if they conceive unwittingly, some form of legal liability may result? After all, with the pace of technological developments such as gene therapy, the serious degenerative late-onset disorder may be curable by the time that infant reaches adulthood. It is also the case that the practical diYculties of recognizing such a duty may also collide with another set of legal principles, namely, membership of the European Union. Cases such as that of Blood send out a powerful message – European regulation is changing the face of health care today, and single jurisdiction regulation may indeed be inadequate in health care law.

Shamans and shamanistic ritual can be traced throughout 18 The Impact of Medicine history order 25 mg precose overnight delivery. Contem porary analysts often discount shamans as healers because o f their alleged use o f chicanery discount 50mg precose amex. For exam­ ple, a common technique am ong shamans is the use of blood-stained down, which is expelled from the m outh after “treatm ent. But this is beside the point; since its im portance was symbolic, this use of down is no different from the prescription of null medications. Jerom e Frank, a psychiatrist at Johns Hopkins who has extensively examined the use of placebos, says of it: The most likely supposition is that it gains its potency through being a tangible symbol of the physician’s role as a healer. In our society, the physician validates his power by prescribing medication, just as a shaman in a primitive tribe may validate his by spitting out a bit of bloodstained down at the proper moment. T he expecta­ tions o f some patients about a treatm ent can alter or even reverse the action of a pharmacological agent. T he subjects did indeed overcome the drug—they experienced no stomach discomfort. W hen disease has a clear em odonal base, the effectiveness of the placebo appears to be enhanced. In one study, pa­ tients with bleeding pepuc ulcers were given a placebo but inform ed that it was a powerful and effective drug. O ther patients were given the same agent but were advised that it was a new and promising experim ental drug of undeter­ m ined effectiveness. T he first group scored 75 percent in their remission rate; the second only 25 percent. T houghtful observers, like Frank, The Impact of Medical Care on Patients 19 think there is m ore to it. T he healer as well as the patient m ust believe in the efficacy of the treatm ent, or at least skillfully convey a state of belief to the patient. As Frank puts it: If the effectiveness of the placebo lies in its ability to mobilize the patient’s expectancy of help, then it should work best with those patients who have favorable expectations from medicine and, in general, accept and respond to symbols of healing. T he placebo, w hether a drug or some other treat­ ment, may serve only as a material symbol of the healer’s power. The placebo effect dem onstrates that medicine can cure some patients through its symbolic presence, simply by being there. If cures can be achieved by a fusion o f the patient’s belief in the treatm ent and the manifestation o f symbols of healing, we must ask if it is possible to use equally effective but less expensive symbols. For centuries healers have adm inistered to pa­ tients, with little impact if m easured by the test of effective­ ness. But medicine worked in the past and still works today, although with mixed results. Medicine has effective technologies— technologies that link what the physician does with what happens to the patient. Most of the research was designed to ascertain optimal conditions for the production of goods. But the investigators discovered an anomaly—whatever they did, 20 The Impact of Medicine production improved. W hen workers believed that m anagem ent cared, w hether by increasing or decreasing the lighting, for example, they tried harder. Some patients given placebos respond better to the null “treatm ent” than those given active drugs. In some studies, groups of patients given placebos had better treatm ent outcomes than groups treated with active medications. One of the dangers, then, of too rigorous an examina­ tion of medicine—requiring proof beyond a reasonable doubt—is that caring might be lost in the process. In procedures such as reduction of frac­ tures; treatm ent of infectious diseases such as diphtheria, tetanus, poliomyelitis, and tuberculosis; and surgery for re­ moval of pathenogenic organs, the physician truly heals. Medical care also heals when it utilizes therapies with which The Impact of Medical Care on Health Status 21 it has been entrusted. Penicillin, sulfa drugs, and antibiotics have expanded the capacity of the medical care system to treat and heal. The capacity to deal effectively with syphilis and tuberculosis represents a milestone in human endeavor, even though full use of this potential has not yet been made. And there are, of course, other examples: the treatment of endo- crinologic disorders with appropriate hormones, the preven­ tion of hemolytic disease of the newborn, the treatment and prevention of various nutritional disorders, and perhaps just around the corner, the management of Parkinsonism and sickle-cell anemia. There are other examples, and everyone will have his favorite candidate for the list, but the truth is that there are not nearly as many as the public has been led to believe. T he Papanicolaou test for cervical cancer has proven utility,39 and the means have been found to treat some forms of skin cancer. Paradoxically, some diseases that are both preventable and treatable continue to strike large num bers of people.

All 99 and universities or specialty addiction treatment states license mental health counselors and buy 50 mg precose overnight delivery, programs--clinical and counseling psychologists with the exception of the “professional †† encounter many patients who engage in risky counselor” license in Illinois buy precose 25mg, all states require substance use or have addiction. Psychologists at least a master’s degree in counseling or a often hold administrative and supervisory related field. The complete at least a semester course in addiction significance of these categories depends on the state’s detection and treatment. The master addictions programs in counseling offer elective courses counselor certification requires (1) a minimum but do not require substance use/addiction- of 12 semester hours of graduate coursework in related course work. Most counseling and (3) a passing score on the examination for degree programs do not provide any addiction 103 107 master addictions counselor. Marriage and certification exam if they pass the national family therapists either must have a master’s 104 exam. Each state widespread use, there is very little research determines the examination required for supporting the efficacy of auricular acupuncture licensure. In Alabama -that require social workers to complete and North Dakota, which do not have licensure † 113 coursework in addiction. A 1998 survey similarly found that 56 percent of licensed addiction counselors 126 Addiction counselors, also known as Substance have at least a master’s degree. Similar to addiction treatment provider staff in facilities the licensure process, certification recognizes providing addiction treatment in the United that addiction counselors have met what the 122 organization deems to be minimum standards of States. In some Addiction counselors can be licensed, certified states addiction counselors must be certified 123 129 or both. The state education qualifications for licensure vary training standards for the credentialing of ‡ 125 addiction counselors--each state certification greatly. The highest level usually documentation; and professional and ethical requires a master’s or doctorate degree. Requirements In spite of the limited education and training include: (1) a current state certificate or license requirements and the apprenticeship model of as an addiction counselor; (2) 270 contact hours training, the essential practice dimensions of of addiction counseling training; (3) three years addiction counseling are defined as including of full-time work experience or 6,000 hours of clinical evaluation; treatment planning; referral; supervised experience as an addiction counselor; service coordination; and individual, group, 138 and (4) successful completion of a written family and couples counseling --practices that 135 examination. In many states, counselors who meet only the † In states where no degree is required, certification minimum education requirements must be requirements typically include 270 hours of supervised. For no other health condition are such exemptions from  Requirements related to services to be routine governmental oversight considered delivered; or acceptable practice. District of Columbia), including the use of the Participation is voluntary and the survey does not Lexis/Nexis database to supplement information represent all treatment providers. A national The federal government does not regulate study of state-run treatment programs found that, addiction treatment facilities or programs, with excluding programs provided or operated by the the exception of those that provide opioid state addiction treatment agencies, only about 149 maintenance therapy. Like state licensing laws, these provisions include requirements regarding  13 states report that their juvenile justice staffing, services and quality assurance system operates treatment programs, with mechanisms. To be eligible to receive Medicare/Medicaid reimbursement, most treatments must be  Seven states identify their departments of provided by or under the supervision of a 151 child and family services as operating physician. State Medicaid programs have the treatment programs, with only four requiring option of covering addiction treatment under the 147 Medicaid rehabilitation option, Medicaid clinic adherence to state licensing standards. The Medicare/Medicaid programs, but in only 11 states are these Conditions of Participation impose extensive programs required to adhere to state requirements on participating facilities including 148 staffing, services and quality assurance licensing standards. While most states do not appear explicitly to address faith-based programs in their laws or regulations, some states explicitly exempt such † programs from regulation. Accreditation generally is required by federal law to obtain certification considered a higher standard of oversight than from the U. While adopting these standards maintenance programs found that voluntary 156 accreditation was strongly related to adoption of largely is voluntary, some states grant licenses 157 these practices; however, after accreditation to programs that have been accredited, such that the program is deemed to have met the state became mandatory in 2000, this relationship licensure requirements because it has been disappeared. The authors speculated that † 158 programs that voluntarily seek accreditation tend approved by a national accrediting body. By granting “deemed status” licenses to accredited to be resource-rich (in funds, staff and training) programs, the state essentially delegates to the and more motivated to improve their quality of accrediting body its responsibility for ensuring care, and therefore more likely to adopt 165 that the facility or program meets state licensure evidence-based practices. Accreditation standards are more detailed than state licensing requirements The five organizations that accredit addiction and while some require facilities and programs treatment programs and facilities in the United to use evidence-based practices or to analyze States are: 160 patient outcomes, not all do. Similarly, facilities voluntarily responding to a national federal requirements stipulate that some types of † survey: care must be provided under the supervision of a physician, while services such as “rehabilitation  56. The categories are Dentists and other health professionals may be not mutually exclusive, as programs and facilities responsible for services they are qualified to perform may have multiple accreditations. Among the 21 medical services are defined as detoxification, states that specify the minimum educational/ opioid replacement therapy or the assessment, training requirements for this position, few have diagnosis and treatment of co-occurring medical particularly high standards: or mental health conditions, not as addiction 181  Eight states require a minimum of a master’s treatment itself. Few states require non-hospital- based programs that do not provide opioid  One state requires an associate’s degree; and maintenance therapy to have a physician serving as medical director or on staff; 10 states require  One state simply requires the person to residential treatment programs to have a demonstrate competence to perform certain physician either as a medical director or on staff services. Without a physician as A national survey of treatment professionals medical director or on staff, addiction treatment conducted in 1998 found that 60. Organizations that seek percent had some college or an associate’s elective accreditation for assertive community ‡ degree and 1. In states that The Joint Commission allows programs to provide addiction treatment using Medicaid define the qualifications required for staff to funding, hospital and clinic services must be perform their job and requires staff who provide 187 provided under the direction of a physician, care to be licensed, certified or registered “in but if states choose to provide services under the accordance with the law. If physician on staff; this person must have services are required to be provided under the experience in addiction medicine, including 193 direction of a physician, the facility physician is medication-assisted treatment. Licensed health care facilities must deliver care The facility and the staff providing care also are that meets standards of medical practice; state required to hold appropriate state licenses, regulations tend to defer to health care 189 certifications or registrations.

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