It is often assumed that the chief responsibility medical professionals bear is patient care and advocacy. The meeting of other duties, such as ensuring a more just distribution of medical resources and promoting the public good, is not considered a legitimate basis for curtailing or slackening beneficial patient services. It is argued that this assumption is often made without sufficient attention to foundational principles of professional ethics; that once core principles are laid bare this assumption is revealed (...) as largely unwarranted; and, finally, that these observations at the level of moral theory should be reflected, in various ways, in medical practice. Specifically, this essay clarifies a tension that exists between different kinds of moral principles and explores the possibility of dissipating that tension by shoring up foundational principles. The paper begins by setting out three alternative models of how best to balance patientadvocacy responsibilities with broader social responsibilities. It then turns to critically assess these models and argue that one has several advantages over the others. (shrink)
The question of whether clinical ethics consultants may engage in patientadvocacy in the course of consultation has not been addressed, but it highlights for the field that consultants? allegiances, and the boundaries of appropriate professional practice, must be better understood. I consider arguments for and against patientadvocacy in clinical ethics consultation, which demonstrate that patientadvocacy is permissible, but not central to the practice of consultation. I then offer four recommendations for consultants (...) who engage in patientadvocacy, and consider the implications of this issue for the field.1. (shrink)
The inevitable need for rationing of healthcare has apparently presented the medical profession with the dilemma of choosing the lesser of two evils. Physicians appear to be obliged to adopt either an implausible version of traditional professional ethics or an equally problematic ethics of bedside rationing. The former requires unrestricted advocacy of patients but prompts distrust, moral hazard and unfairness. The latter commits physicians to rationing at the bedside; but it is bound to introduce unfair inequalities among patients and (...) lack of political accountability towards citizens. In this paper I shall argue that this dilemma is false, since a third intermediate alternative exists. This alternative, which I term 'administrative gatekeeping', makes it possible for physicians to be involved in rationing while at the same time being genuine advocates of their patients. According to this ideal, physicians are required to follow fair rules of rationing adopted at higher organizational levels within healthcare systems. At the same time, however, they are prohibited from including considerations of cost in their clinical decisions. (shrink)
Foreword -- Prologue -- Attorney Eileen Fitzpatrick -- Dr. Jeanne Fitzpatrick -- section 1. Death and dying in America -- 1. The need for change : the cautionary tale of Phyllis Shattuck -- Dr. Fitzpatrick tells Phyllis Shattuck's story -- Reflections -- How this book will help -- Lessons to learn -- New name, old concept -- 2. Your right to die -- Your right to die is born : the case of Karen Ann Quinlan -- The Supreme Court weights (...) in : the case of Nancy Cruzan -- Advance directive forms : an imperfect solution -- The more things change, the more they stay the same : the case of Terri Schiavo -- Moving forward : comfort care only and the Compassion Protocol -- A personal choice -- section 2. Who can use the Compassion Protocol -- 3. The competent elderly -- Dr. Fitzpatrick tells Willa Simpson's story -- Learning from Willa -- The Compassion Protocol increases choice and control at the end of lie -- The Compassion Protocol and the competent elderly -- 4. The terminally ill -- Dr. Fitzpatrick tells Melissa Blackburn's story -- Terminal illness and the Compassion Protocol -- Current practices -- Compassion Protocol practices -- 5. Alzheimer's dementia and the Compassion Protocol -- Dr. Fitzpatrick tells Carl Novack's story -- Alzheimer's dementia and the Compassion Protocol -- Is this really legal? -- Updating time-honored advice -- section 3. How the Compassion Protocol works -- 6. Step one : know your options -- Option one : don't go to the hospital again -- Option two : refuse antibiotics -- Option three : discontinue your usual medications -- Option four : refuse hydration and nutrition -- Health care options summary -- Choosing when your options take effect -- Step one summary -- 7. Step two : make your decisions -- Introduction to step two -- The Compassion Protocol worksheet -- Your list of pros and cons -- A story of our own worst fears -- Step two and the Alzheimer's patient -- Selecting a health care decision maker -- Review -- 8. Step three : communicate your decisions -- The importance of full and adequate communication : the story of Ray Sullivan -- What constitutes effective communication? -- Tell your health care decision maker -- Tell your doctor and other health care providers -- Tell your family -- Tell your friends -- Dr. Fitzpatrick talks about her end-of-life choices -- Attorney Fitzpatrick talks about her end-of-life choices -- Step three summary -- 9. Step four : do the paperwork -- Introduction to the Contract for Compassionate Care -- Legal basis of the Compassion Protocol -- The long and short of legal forms -- And never forget the "people" part -- 10. Step five : plan the kind of death you want -- Changing society one death at a time -- 11. Hospice and the Compassion Protocol -- The importance of fighting for life and of letting go : Dr. Fitzpatrick tells the story of one patient's experience with hospice -- The team approach -- Paying for hospice -- Hospice and the Compassion Protocol -- 12. Everyone's worst fear : the nursing home -- Dr. Fitzpatrick relates the story of Sean O'Connor : a regrettably common nursing home experience -- Understanding you nursing home option -- Nursing homes : a growth business -- The home health care alternative -- When the system works : Dr. Fitzpatrick tells the story of Sally Forest -- Reflections -- 13. Looking ahead -- Appendix A. Contract for Compassionate Care -- Appendix B. Tools for the Compassion Protocol -- Glossary. (shrink)
Issues concerning patients' rights are at the center of bioethics, but the political basis for these rights has rarely been examined. In Bioethics in a Liberal Society: The Political Framework of Bioethics Decision Making , Thomas May offers a compelling analysis of how the political context of liberal constitutional democracy shapes the rights and obligations of both patients and health care professionals. May focuses on how a key feature of liberal society -- namely, an individual's right to make independent decisions (...) -- has an impact on the most important relational facets of health care, such as patients' autonomy and professionals' rights of conscience. Although a liberal political framework protects individual judgments, May asserts that this right is based on the assumption of an individual's competency to make sound decisions. May uses case studies to examine society's approach to medical decision making when, for reasons ranging from age to severe mental disorder, a person lacks sufficient competency to make independent and fully informed choices. To protect the autonomy of these vulnerable patients, May emphasizes the need for health care ethics committees and ethics consultants to help guide the decision-making process in clinical settings. Bioethics in a Liberal Society is essential reading for all those interested in understanding how bioethics is practiced within our society. (shrink)
Background: Medical tourism involves patients travelling internationally to receive medical services. This practice raises a range of ethical issues, including potential harms to the patient's home and destination country and risks to the patient's own health. Medical tourists often engage the services of a facilitator who may book travel and accommodation and link the patient with a hospital abroad. Facilitators have the potential to exacerbate or mitigate the ethical concerns associated with medical tourism, but their roles are (...) poorly understood. -/- Methods: 12 facilitators were interviewed from 10 Canadian medical tourism companies. -/- Results: Three themes were identified: facilitators' roles towards the patient, health system and medical tourism industry. Facilitators' roles towards the patient were typically described in terms of advocacy and the provision of information, but limited by facilitators' legal liability. Facilitators felt they played a positive role in the lives of their patients and the Canadian health system and served as catalysts for reform, although they noted an adversarial relationship with some Canadian physicians. Many facilitators described personally visiting medical tourism sites and forming personal relationships with surgeons abroad, but noted the need for greater regulation of their industry. -/- Conclusion: Facilitators play a substantial and evolving role in the practice of medical tourism and may be entering a period of professionalisation. Because of the key role of facilitators in determining the effects of medical tourism on patients and public health, this paper recommends a planned conversation between medical tourism stakeholders to define and shape facilitators' roles. (shrink)
Substantial efforts have recently been made to reform the physician-patient relationship, particularly toward replacing the `silent world of doctor and patient' with informed patient participation in medical decision-making. This 'new ethos of patient autonomy' has especially insisted on the routine provision of informed consent for all medical interventions. Stronly supported by most bioethicists and the law, as well as more popular writings and expectations, it still seems clear that informed consent has, at best, been received in (...) a lukewarm fashion by most clinicians, many simply rejecting what they commonly refer to as the `myth of informed consent'. The purpose of this book is to defuse this seemingly intractable controversy by offering an efficient and effective operational model of informed consent. This goal is pursued first by reviewing and evaluating, in detail, the agendas, arguments, and supporting materials of its proponents and detractors. A comprehensive review of empirical studies of informed consent is provided, as well as a detailed reflection on the common clinician experience with attempts at informed consent and the exercise of autonomy by patients. In the end, informed consent is recast as a management tool for pursuing clinically and ethically important goods and values that any clinician should see as meriting pursuit. Concurrently, the model incorporates a flexible, anticipatory approach that recognizes that no static, generic ritual can legitimately pursue the quite variable goods and values that may be at stake with different patients in different situations. Finally, efficiency of provision is addressed by not pursuing the unattainable and ancillary. Throughout, the traditional principle of beneficence is appealed to toward articulating an operational model of informed consent as an intervention that is likely to change outcomes at the bedside for the better. (shrink)
In this eye-opening look at the doctor-patient decision-making process, physician and law professor Jay Katz examines the time-honored belief in the virtue of silent care and patient compliance. Historically, the doctor-patient relationship has been based on a one-way trust -- despite recent judicial attempts to give patients a greater voice through the doctrine of informed consent. Katz criticizes doctors for encouraging patients to relinquish their autonomy, and demonstrates the detrimental effect their silence has on good patient (...) care. Seeing a growing need in this age of medical science and sophisticated technology for more honest and complete communication between physician and patients, he advocates a new, informed dialogue that respects the rights and needs of both sides. In a new foreword to this edition of The Silent World of Doctor and Patient , Alexander Morgan Capron outlines the changes in medical ethics practice that have occurred since the book was first published in 1984, paying particular attention to the hotly debated issues of physician-assisted suicide and informed consent in managed care. (shrink)
By considering the nature of the relationship between patient and healer, The Healing Bond explores the responsibilities of both, with a special emphasis on the therapeutic responsibility. The editors and contributors examine both orthodox and unorthodox forms of healing practice and apply a variety of professional and analytic perspectives to the medical profession as a whole. They look at specific areas of health such as midwifery, psychoanalysis, naturopathy, the relations between medicine and state, and the appeal of "quacks." Particular (...) issues of current concern are also discussed, including medical litigation, codes of ethics among complementary practitioners and cooperation between orthodox and complementary medicine practitioners. Contributors: Mary Douglas, Calliope Farsides, David Peters, Roy Porter, Richenda Power, Margaret Stacey, Robert Sumerling, and Gillian Vanhegan. (shrink)
A 16 year old Hodgkin lymphoma patient refuses to have his blood specimen drawn, thus canceling his scheduled oncologic treatment. As a 16 year old, he has no legal standing as an adult. His parents are split over his decision. One supports his right to choose; the other wishes the specimen to be drawn and the chemotherapy reinstated. The physicians at the hospital are seeking legal redress to have the court order the blood specimens to be taken.
Argumentation theory has much to offer our understanding of the doctor-patient relationship as it plays out in the context of seeking and obtaining consent to treatment. In order to harness the power of argumentation theory in this regard, I argue, it is necessary to take into account insights from the legal and bioethical dimensions of informed consent, and in particular to account for features of the interaction that make it psychologically complex: that there is a fundamental asymmetry of authority, (...) power and expertise between doctor and patient; that, given the potential for coercion, it is a challenge to preserve the interactive balance presumed by the requirement of informed consent; and finally that the necessary condition that patients be ‘competent to consent’ may undermine the requirement of respecting patient autonomy. I argue argumentation theory has the resources to deal with these challenges and expand our knowledge, and appreciation, of the informed consent interaction in health care. Keywords: argumentation theory, informed consent, doctor-patient interaction, competency to consent, autonomy, medical paternalism. (shrink)
Background Following passage of the Patient Self Determination Act in 1990, health care institutions that receive Medicare and Medicaid funding are required to inform patients of their right to make their health care preferences known through execution of a living will and/or to appoint a surrogate-decision maker. We evaluated the impact of external factors and perceived patient preferences on physicians’ decisions to honor or forgo previously established advance directives (ADs). In addition, physician views regarding legal risk, patients’ ability (...) to comprehend complexities involved with their care, and impact of medical costs related to end-of-life care decisions were explored. Methods Attendees of two Mayo Clinic continuing medical education courses were surveyed. Three scenarios based in part on previously court-litigated matters assessed impact of external factors and perceived patient preferences on physician compliance with patient-articulated wishes regarding resuscitation. General questions measured respondents’ perception of legal risk, concerns over patient knowledge of idiosyncrasies involved with their care, and impact medical costs may have on compliance with patient preferences. Responses indicating strength of agreement or disagreement with statements were treated as ordinal data and analyzed using the Cochran Armitage trend test. Results Three hundred eighty-eight of 951 surveys were completed (41% response rate). Eighty percent reported they were likely to honor a patient’s AD despite its 5 year age. Fewer than half (41%) would honor the AD of a patient in ventricular fibrillation who had expressed a desire to “pass away in peace.” Few (17%) would forgo an AD following a family’s request for continued resuscitative treatment. A majority (52%) considered risk of liability to be lower when maintaining someone alive against their wishes than mistakenly failing to provide resuscitative efforts. A large percentage (74%) disagreed that patients could not appreciate complexities surrounding their care while 69% agreed that costs should never impact a physician’s decision as to whether to comply with a patient’s AD. Conclusions Our findings highlight the impact, albeit small, external factors have on physician AD compliance. Most respondents based their decision on the clinical situation at hand and interpretation of the patient’s initial wishes and preferences expressed by the AD. (shrink)
Trust in the doctor-patient relationship is an indispensable structural element for the medical profession. The discourse concerning trust and its importance in the healthcare context, although quite old, elicits increasingly more interest in research, especially for empirical approaches. The importance of trust in the doctor and in the medical profession can be demonstrated by starting from the Christian meaning of illness and medicine ; generally, the patristic sources see medicine and physicians as God’s gifts. T he perception of Christian (...) physicians as dedicated, unselﬁsh and compassionate preservers or restorers of health, always committed to the good of their patients is well known. The model of the Christian physician is a Hippocratic model, of one who seeks the sick so that he may bring relief to them and strengthen them. When illness occurs, Christianity affirms an ethical duty to struggle against sickness, which if unaddressed can lead to death. The moral requirement to care for the health of the body indicates it is appropriate to use healing methods that will enhance health and maintain life. The aim of this paper is to explore the dimensions of the concept of trust in the doctor-patient relationship, by starting from the Christian meaning of illness and of the role of the doctor. The paper presents a number of essential theoretical elements related to trust, as presented in the literature dealing with the doctor-patient relationship: the meaning of trust, its dimensions, its stages of development, its impact, its sources, the patient’s perspectives on trust, the importance of trust for healthcare systems. (shrink)
In this companion volume to their 1981 work, A Philosophical Basis of Medical Practice, Pellegrino and Thomasma examine the principle of beneficence and its role in the practice of medicine. Their analysis, which is grounded in a thorough-going philosophy of medicine, addresses a wide array of practical and ethical concerns that are a part of health care decision-making today. Among these issues are the withdrawing and withholding of nutrition and hydration, competency assessment, the requirements for valid surrogate decision-making, quality-of-life determinations, (...) the allocation of scarce health care resources, medical gatekeeping, and for-profit medicine. The authors argue for the restoration of beneficence (re-interpreted as beneficence-in-trust) to its place as the fundamental principle of medical ethics. They maintain that to be guided by beneficence a physician must perform a right and good healing action which is consonant with the individual patient's values. In order to act in the patient's best interests, or the patient's good, the physician and patient must discern what that good is. This knowledge is gained only through a process of dialogue between patient and/or family and physician which respects and honors the patient's autonomous self-understanding and choice in the matter of treatment options. This emphasis on a dialogical discernment of the patient's good rejects the assumption long held in medicine that what is considered to be the medical good is necessarily the good for this patient. In viewing autonomy as a necessary condition of beneficence, the authors move beyond a trend in the medical ethics literature which identifies beneficence with paternalism. In their analysis of beneficence, the authors reject the current emphasis on rights- and duty-based ethical systems in favor of a virtue-based theory which is grounded in the physician-patient relationship. This book's provocative contributions to medical ethics will be of great interest not only to physicians and other health professionals, but also to ethicists, students, patients, families, and all others concerned with the relationship of professional to patient and patient to professional in health care today. (shrink)
The puzzling case of the broken arm -- Hernias, diets, and drugs -- Why physicians cannot know what will benefit patients -- Sacrificing patient benefit to protect patient rights -- Societal interests and duties to others -- The new, limited, twenty-first-century role for physicians as patient assistants -- Abandoning modern medical concepts: doctor's "orders" and hospital "discharge" -- Medicine can't "indicate": so why do we talk that way? --"Treatments of choice" and "medical necessity": who is fooling whom? (...) -- Abandoning informed consent -- Why physicians get it wrong and the alternatives to consent: patient choice and deep value pairing -- The end of prescribing: why prescription writing is irrational -- The alternatives to prescribing -- Are fat people overweight? -- Beyond prettiness: death, disease, and being fat -- Universal but varied health insurance: only separate is equal -- Health insurance: the case for multiple lists -- Why hospice care should not be a part of ideal health care I: the history of the hospice -- Why hospice care should not be a part of ideal health care II: hospice in a postmodern era -- Randomized human experimentation: the modern dilemma -- Randomized human experimentation: a proposal for the new medicine -- Clinical practice guidelines and why they are wrong -- Outcomes research and how values sneak into finding of fact -- The consensus of medical experts and why it is wrong so often. (shrink)
The recent confirmation of the constitutionality of the Obama administration’s Patient Protection and Affordable Care Act (PPACA) by the US Supreme Court has brought to the fore long-standing debates over individual liberty and religious freedom. Advocates of personal liberty are often critical, particularly in the USA, of public health measures which they deem to be overly restrictive of personal choice. In addition to the alleged restrictions of individual freedom of choice when it comes to the question of whether or (...) not to purchase health insurance, opponents to the PPACA also argue that certain requirements of the Act violate the right to freedom of conscience by mandating support for services deemed immoral by religious groups. These issues continue the long running debate surrounding the demands of religious groups for special consideration in the realm of health care provision. In this paper I examine the requirements of the PPACA, and the impacts that religious, and other ideological, exemptions can have on public health, and argue that the exemptions provided for by the PPACA do not in fact impose unreasonable restrictions on religious freedom, but rather concede too much and in so doing endanger public health and some important individual liberties. (shrink)
The purpose of this paper is to provide a normative model for the assessment of the exercise of power by Big Pharma. By drawing on the work of Steven Lukes, it will be argued that while Big Pharma is overtly highly regulated, so that its power is indeed restricted in the interests of patients and the general public, the industry is still able to exercise what Lukes describes as a third dimension of power. This entails concealing the conflicts of interest (...) and grievances that Big Pharma may have with the health care system, physicians and patients, crucially through rhetorical engagements with PatientAdvocacy Groups that seek to shape public opinion, and also by marginalising certain groups, excluding them from debates over health care resource allocation. Three issues will be examined: the construction of a conception of the patient as expert patient or consumer; the phenomenon of disease mongering; the suppression or distortion of debates over resource allocation. (shrink)
A distinction is made between the function of ethics in clinical medicine, which is to guide the clinician in his/her practice, and the role of the ethicist. It suggests that ethicists can help by clarifying values expressed in various clinical behaviours. The author proposes that certain ethical positions, such as patientadvocacy, have compromised the privacy of the doctor-patient relationship and created a potential for ethical leverage through financial-legal consequences they did not intend or foresee.
This study examines the public's and physicians' willingness to support deception of insurance companies in order to obtain necessary healthcare services and how this support varies based on perceptions of physicians' time pressures. Based on surveys of 700 prospective jurors and 1617 physicians, the public was more than twice as likely as physicians to sanction deception (26% versus 11%) and half as likely to believe that physicians have adequate time to appeal coverage decisions (22% versus 59%). The odds of public (...) support for deception compared to that of physicians rose from 2.48 to 4.64 after controlling for differences in time perception. These findings highlight the ethical challenge facing physicians and patients in balancing patientadvocacy with honesty in the setting of limited societal resources. (shrink)
Linda Morrison brings the voices and issues of a little-known, complex social movement to the attention of sociologists, mental health professionals, and the general public. The members of this social movement work to gain voice for their own experience, to raise consciousness of injustice and inequality, to expose the darker side of psychiatry, and to promote alternatives for people in emotional distress. Talking Back to Psychiatry explores the movement's history, its complex membership, its strategies and goals, and the varied response (...) it has received from psychiatry, policy makers, and the public at large. (shrink)
In this paper, I address some of the shortcomings of established clinical ethics centring on personal autonomy and consent and what I label the Doctrine of Respecting Personal Autonomy in Healthcare. I discuss two implications of this doctrine: 1) the practice for treating patients who are considered to have borderline decision-making competence and 2) the practice of surrogate decision-making in general. I argue that none of these practices are currently aligned with respectful treatment of vulnerable individuals. Because of 'structural arbitrariness' (...) in the whole process of how we assess decision-making competence, this area is open to disrespectful treatment of people. The practice of surrogate decision- making on the basis of a single person's judgment is arguably not consistent with ethical and political requirements derived from the doctrine itself. In response to the inadequacies of the doctrine, I suggest a framework for reasonableness in surrogate decision-making which might allow practice to avoid the problems above. I conclude by suggesting an extended concept of Patient Autonomy which integrates both personal autonomy and the regulative idea of morality that is required by reasonableness in deciding for non-competent others. (shrink)
This essay argues that philosophical phenomenology can provide important insights into the patient-physician relationship. In particular, it is noted that the physician and patient encounter the experience of illness from within the context of different "worlds", each "world" providing a horizon of meaning. Such phenomenological notions as focusing, habits of mind, finite provinces of meaning, and relevance are shown to be central to the way these "worlds" are constituted. An eidetic interpretation of illness is proposed. Such an interpretation (...) discloses certain essential characteristics that pertain to the experience of illness, per se , regardless of its manifestation in terms of a particular disease state. It is suggested that, if a shared world of meaning is to be constituted between physician and patient, the eidetic characteristics of illness must be recognized by the physician. Keywords: phenomenology, patient-physician relationship, illness-as-lived, habits of mind, relevance, eidetic CiteULike Connotea Del.icio.us What's this? (shrink)
According to the principle of patient autonomy, patients have the right to be self-determining in decisions about their own medical care, which includes the right to refuse treatment. However, a treatment refusal may legitimately be overridden in cases where the decision is judged to be incompetent. It has recently been proposed that in assessments of competence, attention should be paid to the evaluative judgments that guide patients' treatment decisions.In this paper I examine this claim in light of theories of (...) practical rationality, focusing on the difficult case of an anorexic person who is judged to be competent and refuses treatment, thereby putting themselves at risk of serious harm. I argue that the standard criteria for competence assess whether a treatment decision satisfies the goals of practical decision-making, and that this same criterion can be applied to a patient's decision-guiding commitments. As a consequence I propose that a particular understanding of practical rationality offers a theoretical framework for justifying involuntary treatment in the anorexia case. (shrink)
The author applies a feminist analysis to animal advocacy initiatives in which gendered and racialized representations of female sexuality are paramount. Feminists have criticized animal advocates for opposing the oppression of nonhuman animals through media images that perpetuate female objectification. These critiques are considered through a close examination of two prominent campaigns by PETA (People for the Ethical Treatment of Animals). The author argues that some representations of female sexuality may align with a posthumanist feminist ethic and need not (...) be read as sexist. Examining PETA’s famous anti-fur ads and the more recent Milk Gone Wild campaign, the author identifies where PETA’s campaigns are objectionable under a feminist ethic and where they are subversive of an anthropocentric and male-dominated order alike. The article thus recuperates part of PETA’s work from feminist critiques, but also reveals the constructions posthumanist advocacy should exclude to avoid elevating the status of nonhuman animals at the expense of women. (shrink)
In patient-centred care, shared decision-making is advocated as the preferred form of medical decision-making. Shared decision-making is supported with reference to patient autonomy without abandoning the patient or giving up the possibility of influencing how the patient is benefited. It is, however, not transparent how shared decision-making is related to autonomy and, in effect, what support autonomy can give shared decision-making. In the article, different forms of shared decision-making are analysed in relation to five different aspects (...) of autonomy: (1) self-realisation; (2) preference satisfaction; (3) self-direction; (4) binary autonomy of the person; (5) gradual autonomy of the person. It is argued that both individually and jointly these aspects will support the models called shared rational deliberative patient choice and joint decision as the preferred versions from an autonomy perspective. Acknowledging that both of these models may fail, the professionally driven best interest compromise model is held out as a satisfactory second-best choice. (shrink)
I shall draw on my experience of being an ICU patient to make some practical, ethical, and philosophical points about the care of the critically ill. The recurring theme in this paper is ICU psychosis. I suggest that discharged patients ought to be educated about it; I discuss the obstacles in the way of accurately measuring it; I argue that we must rethink autonomy in light of it; and I suggest that the self disintegrates in the face of it.
Bioethics is a subject far removed from the Chinese, even from many Chinese medical students and medical professionals. In-depth interviews with eighteen physicians, patients, and family members provided a deeper understanding of bioethical practices in contemporary China, especially with regard to the doctor-patient relationship (DPR) and informed consent. The Chinese model of doctor-family-patient relationship (DFPR), instead of DPR, is taken to reflect Chinese Confucian cultural commitments. An examination of the history of Chinese culture and the profession of medicine (...) in China is used to disclose the deep roots of these commitments. The author predicts that the DFPR model will further develop in China but that it will maintain its Chinese character. (shrink)
This article explores the ethical concept of neutrality through use of a psychiatric clinical vignette. In this case a psychiatry resident is faced with the treatment of a patient who was found by the FBI to be in possession of child pornography. Although not accused of any other crimes, the patient was a fugitive from the law and requesting treatment for pedophilia. Faced with the pressures of limited resources and anxiety about the patient's dangerousness to others, the (...) resident and his supervisor tried to strike a balance between the ethical principles of neutrality and beneficence. Through this vignette, the importance of neutrality, as well as how it can be compromised by other pressures such as expediency and anxiety, is explored. (shrink)
One way to understand philosophy as a form of therapy is this: it involves a philosopher who is trying to cure himself. He has been drawn into a certain philosophical frame of mind—the ‘disease’—and has thus infected himself with this illness. Now he is sick and trying to employ philosophy to cure himself. So philosophy is both: the ailment and the cure. And the philosopher is all three: pathogenic agent, patient, and therapist.
This article provides a summary overview of the ideas on medical anthropology and anthropological medicine of the German philosopher-psychiatrist Viktor Emil von Gebsattel (1883–1974), and discusses in more detail his views on the doctor-patient relationship. It is argued that Von Gebsattel''s warning against a dehumanization of medicine when the person of both patient and physician are not explicitly present in their relationship remains valid notwithstanding the modern emphasis on respect for patient (and provider) autonomy.
: Mothers serve as an important layer of the health-care system, with special responsibilities to care for the health of families and nations. In our social discourse, we tend to treat maternal "choices" as though they were morally and causally self-contained units of influence with primary control over children's health. In this essay, I use infant feeding as a lens for examining the ethical contours of mothers' caretaking practices and responsibilities, as they are situated within cultural meanings and institutional pressures. (...) I give a close critical reading of the content and strategy of the new breastfeeding advocacy campaign sponsored by the United States Department of Health and Human Services. I argue that the campaign is unlikely to substantially increase breastfeeding rates, unresponsive and even hostile to many women's actual concerns about breastfeeding, and well positioned to produce shame and compromise agency among the women it targets. (shrink)
The article draws from a personal clinical experience of two suicides, not far removed from each other in time. The first patient was a 33-year-old intellectual suffering from depression with narcissistic traits but no psychotic elements, while the second patient was a 21-year-old student with a manifest psychotic episode behind him and with characteristics of post-psychotic depression at the time of suicide. The two suicides had very different impacts on the therapist: the first left open some “space” for (...) reflection, communication, and working-through, while the second closed such a “space,” leaving only a tiny door to the existential roots of human beings and suffering. The therapist was able to find some “shelter” by talking to supervisors, colleagues, and friends in the first case; in the second, the only possible “shelter” was glimpsed in the philosophy of groundlessness (Ungrund) of the Russian existentialist Nicolai Berdyaev. The personal experiences of the therapist, along with some theoretical interpretations of the after-effects of both suicides, are presented using a psychodynamic and existential–phenomenological understanding of the therapeutic relationship with a psychotic and a non-psychotic patient. The main dilemmas exposed by a patient’s suicide, especially if the patient suffers from psychosis, are difficult to deal with in the usual clinical settings and call for resources beyond it. The authors propose that these can be found in philosophical and theological insights. (shrink)
In this paper, we provide a new framework for understanding infant-feeding-related maternal guilt and shame, placing these in the context of feminist theoretical and psychological accounts of the emotions of self-assessment. Whereas breastfeeding advocacy has been critiqued for its perceived role in inducing maternal guilt, we argue that the emotion women often feel surrounding infant feeding may be better conceptualized as shame in its tendency to involve a negative self-assessment—a failure to achieve an idealized notion of good motherhood. Further, (...) we suggest, both formula-feeding and breastfeeding mothers experience shame: the former report feeling that they fail to live up to ideals of womanhood and motherhood, and the latter transgress cultural expectations regarding feminine modesty. The problem, then, is the degree to which mothers are vulnerable to shame generally, regardless of infant feeding practices. As an emotion that is less adaptive and potentially more damaging than guilt, shame ought to be the focus of resistance for both feminists and breastfeeding advocates, who need to work in conjunction with women to oppose this shame by assisting them in constructing their own ideals of good motherhood that incorporate a sense of self-concern. (shrink)
In this article, I discuss the ethical need for competence in the assessment and management of the suicidal patient, and further suggest that this specific competence be considered a routine element in professional psychological practice. I also argue that this particular competence necessitates adequate training in working with this high-risk population, as well as the need for every clinician to personally evaluate her or his own technical and personal competencies to work with suicidal patients before beginning independent practice activities (...) in clinical situations wherein he or she may be called on to evaluate or treat a suicidal patient. This article concludes with a discussion of specific ethical dilemmas (e.g., the issue of confidentiality), and a list of suggestions for specific competencies in working with the suicidal patient is provided. (shrink)
Patient-reported outcome measures (PROMs) are increasingly used to assess multiple facets of healthcare, including effectiveness, side effects of treatment, symptoms, health care needs, quality of care, and the evaluation of health care options. There are thousands of these measures and yet there is very little discussion of their theoretical underpinnings. In her 2008 Presidential address to the Society for Quality of Life Research (ISOQoL), Professor Donna Lamping challenged researchers to grapple with the theoretical issues that arise from these measures. (...) In this paper, I attempt to do so by arguing for an analogy between PROMs and Hans-Georg Gadamer’s logic of question and answer. While researchers readily admit that the constructs involved in PROMs are imperfectly understood and lack a gold standard, they often ignore the consequences of this fact. Gadamer’s work on questions and their importance to philosophical hermeneutics helps to show that the questions researchers ask about such constructs are also imperfectly understood. I argue that these questions should not be standardized, and I instead propose a theoretical framework that understands PROMs as posing genuine questions to respondents—questions that are open to reinterpretation. (shrink)
The growth of managed care was accompanied by concern about the impact that changes in health care organization would have on the doctor-patient relationship (DPR). We now are in a "post-managed care era," where some of these changes in health care delivery have come to pass while others have not. A re-examination of the DPR in this setting suggests some surprising results. Rather than posing a new and unprecedented threat, managed care was simply the most recent of numerous strains (...) on the DPR that have occurred throughout the century. These strains are a constant, inevitable consequence of the varying needs and concerns of patient and physicians as they seek to balance their desires for a certain type of DPR with their simultaneous desire for other aspects of care such as lower costs, greater technological sophistication, and improved outcomes. (shrink)
This paper examines the power relations in “patient-centred communication”. Drawing on the work of Michel Foucault I argue that while patient-centred communication frees the patient from particular aspects of medical power, it also introduces the patient to new power relations. The paper uses a Foucauldian analysis of power to argue that patient-centred communication introduces a new dynamic of power relations to the medical encounter, entangling and producing the patient to participate in the medical encounter (...) in a particular manner. (shrink)
In this essay, I examine the controversy concerning the advocacy of ethical values in conservation biology. First, I argue, as others have, that conservation biology is a science laden with values both ethical and non-ethical. Second, after clarifying the notion of advocacy at work, I contend that conservation biologists should advocate the preservation of biological diversity. Third, I explore what ethical grounds should be used for advocating the preservation of ecological systems by conservation biologists. I argue that conservation (...) biologists should defend their preservationist positions on instrumentalist grounds alone if the context of discussion and debate is a scientific one. (shrink)
The Patient Protection and Affordable Care Act (ACA) sets in motion a wide range of programs that substantially affected the health system in the United States and signify a moderate but important regulatory shift in the role of the federal government in public health. This article briefly addresses two interesting policy paradoxes about the ACA. First, while the legislation primarily addresses health care financing and insurance and establishes only a few initiatives directly targeting public health, the ACA nevertheless has (...) the potential to produce extensive public health benefits across the United States population by improving access to health care and services and reducing cost. Essentially, the ACA does not take the explicit form of a public health law but instead strives to advance public health indirectly through its effects. Second, while the ACA does not establish a right to health — or even a right to health insurance — in the United States, it does set in motion a number of significant structural and normative changes to United States law that comport with the attainment of the right to health. Most significantly, key provisions of the bill are designed to improve availability, accessibility, acceptability, and quality of conditions necessary for health, and to prompt the government to respect, protect, and fulfill these conditions. These developments mean that, to a degree, the United States essentially has undertaken the same types of legal and policy steps that a country would be required to take to uphold the right to health without actually recognizing the right to health in any formal or legally binding way.Despite these dual paradoxes and the upside potential for public health improvements resulting from the ACA, the public health impact of the law remains uncertain and will be decided by numerous subsequent regulatory and implementation decisions. The ACA authorizes multiple federal agencies to engage in rulemaking, a process that will largely dictate the systemic and health impacts that will become its legacy. This reality opens up ample opportunity to bolster public health aspects and interpretations of the law, and to simultaneously augment the corresponding components of the right to health. (shrink)
This paper utilizes Iris Marion Young’s critical, post-9/11 reading of Thomas Hobbes, as a theorist of authoritarian government grounded in fear of threat (Young 2003). Applying Young’s reading of Hobbes to the high-profile ethicist Julian Savulescu’s advocacy of genetic enhancement reveals an underlying unjust discrimination in Savulescu’s use of patriarchal protector–protected analogies between family and state. First, the paper shows how Savulescu’s concept of procreative beneficence, in which parents use genetic selection to have children who will have the best (...) lives possible, is unjustly discriminatory against marginalized groups. Increasingly, however, he has invoked public security to justify genetic interventions. In recent speeches, Savulescu has argued a global state of emergency is developing due to a combination of the global environmental crisis, the threat of bioterrorism, and the failure of liberalism. To help deal with this emerging state of emergency, Savulescu advocates an unjustly discriminatory array of genetic-based governance practices, including detention and segregation. (shrink)
This article explores the patient consent process in modern community pharmacy practice and discusses the related ethical dilemmas in this environment. The myth of appropriately informed consent, and irrefutable evidence as to a pharmacist’s intentions when advising a patient, are core issues for discussion. The objective is to clarify where such dilemmas may exist in the consent process and to ultimately form a framework against which ethical guidelines might facilitate resolution of the dilemma faced by the pharmacist who (...) is expected to simultaneously maintain legal and duty of care responsibilities in the patient consent process. (shrink)
Boundaries in the doctor–patient relationshipis an important concept to help healthprofessionals navigate the complex andsometimes difficult experience between patientand doctor where intimacy and power must bebalanced in the direction of benefitingpatients. This paper reviews the concept ofboundary violations and boundary crossings inthe doctor–patient relationship, cautions aboutcertain kinds of boundary dilemmas involvingdual relationships, gift giving practices,physical contact with patients, andself-disclosure. The paper closes with somerecommendations for preventing boundaryviolations.
In the principles of informed consent we state that each person ought to be free to make his or her own decisions regarding his or her life and health — provided that he or she is mentally competent to do so. Here, the concept of competence plays a crucial role. Where one is competent our moral goal is to promote his or her freedom; if he or she is not, our priority must be to protect and help him or her. (...) In this paper I discuss three different notions of patient competence. The first, rational competence, concerns the basic ability to make a decision. The second, performance competence, concerns one's ability to make decisions and perform skills in ways that measure up to certain external standards. The third, reflective competence, concerns one's ability to identify and critically to scrutinize one's own values — one's ability, that is, to formulate and to evaluate one's own internal standards of decision and action. This richer analysis of the concept of competence enables us to formulate more precisely the moral difficulties we face when competence is impaired. (shrink)
Patient counseling is a cornerstone of ethical pharmacy practice and high quality pharmaceutical care. Counseling promotes patient compliance with prescription regimens and prevents dangerous drug interactions and medication errors. Counseling also promotes informed consent and protects pharmacists against legal risks. However, economic, social, and technological changes in pharmacy practice often force community pharmacists to choose between their professional obligations to counsel patients and business objectives. State and federal legislatures have enacted laws that require pharmacists to counsel patients, but (...) these laws have had mixed results. This essay argues that community pharmacy's patient counseling conundrum can be solved through additional moral education and moral persuasion, not through additional legal mandates. (shrink)
Although bioethics is a lively and expanding interdisciplinary field, there is not enough research about the patient-doctor relationship, a central issue in philosophy of medicine. This article surveys the state of the field, paying attention to recent work by Alfred Tauber, and supplementing it with insights from Hans Jonas's philosophy of technology in order to propose a principle of responsible autonomy for health care. Based on a comparative look across different sub-fields in bioethics, the resulting model claims that physician (...) responsibility is essential to professional integrity, providing an alternative to other active trends emphasizing patient autonomy, such as Robert Veatch's contractual model. (shrink)
In this paper, I examine the notion of accountability and its historical evolution in health care. Using medical mistakes and adverse patient outcomes as my focus, I examine the interests served by particular models of accountability and argue for a model of collective fiduciary responsibility in U.S. health care today.
Advance directives are not a part of the healthcare service in Turkey. This may be related with the fact that paternalism is common among the healthcare professionals in the country, and patients are not yet integrated in the decision-making process adequately. However, starting from the enactment of the Regulation of Patient Rights in 1998, this situation started to change. While the paternalist tradition still appears to be strong in Turkey, the Ministry of Health has been taking concrete measures in (...) the recent years to ensure that patient rights are implemented in healthcare practice. Therefore, Turkey now seems to be in a transitional period where a move towards a more patient-autonomy centred approach is being supported by the regulatory authorities, as well as the academic circles and the public at large. In the light of this background, this paper aims to examine the potential benefits of advance directives, particularly with regard to their possible effect in the clinical decision-making process of Turkey's context. It will be argued that advance directives, if correctly understood and implemented in the right settings, may be beneficial, particularly for improving communication between patients and healthcare professionals and for implementing of the right to refuse treatment. (shrink)
A review of the philosophical debate on theoretical models for the physician-patient relationship over the past fifteen years may point to some of the more productive questions for future research. Contractual models have been criticized for promoting a legalistic and minimalistic image of the relationship, such that another form of model (such as convenant) is required. Shifting from a contractual to a contractarian model (in keeping with Rawls' notion of an original position) provides an adequate response to many criticisms (...) of this type. A deeper criticism, however, is one that advocates a shift to a virtue-based approach. A creative amalgam between a contractarian model and elements of the virtue-based approach, combined with appropriate empirical investigation, may yield richer models in the future. (shrink)
This essay focuses on the doctor-patient relationship as a measure of ethical behavior by the physician. The perspective is derived from commitment as a religious humanist to the Judaic heritage, and experience in hospitals. The ethical responsibility to be competent professionally is presupposed. Emphasis is placed on the need of the physician to respect the autonomy of the patient as person, thus to limit the paternalism inherent in the physician's position, and to re-enforce this with compassion. Judaic sources (...) supporting such conduct are cited. Exception is taken to decisions by civil and rabbinic judges which disregard the intimacy of the doctor-patient relationship. Keywords: doctor-patient relationship, bioethics, Judaism, compassion, paternalism, autonomy CiteULike Connotea Del.icio.us What's this? (shrink)
Torture is unethical and usually counterproductive. It is prohibited by international and national laws. Yet it persists: according to Amnesty International, torture is widespread in more than a third of countries. Physicians and other medical professionals are frequently asked to assist with torture. -/- Medical complicity in torture, like other forms of involvement, is prohibited both by international law and by codes of professional ethics. However, when the victims of torture are also patients in need of treatment, doctors can find (...) themselves torn. To accede to the requests of the torturers may entail assisting or condoning terrible acts. But to refuse care to someone in medical need may seem like abandoning a patient and thereby fail to exhibit the beneficence expected of physicians. -/- In this paper, we argue that this dilemma is real and that sometimes the right thing for a doctor to do, overall, is to be complicit in torture. Though complicity in a wrongful act is itself prima facie wrongful, this judgment may be outweighed by other factors. We propose three criteria for analyzing how those factors apply to particular cases of medical complicity in torture. (shrink)
The clinical application of the concept of patient autonomy has centered on the ability to deliberate and make treatment decisions (decisional autonomy) to the virtual exclusion of the capacity to execute the treatment plan (executive autonomy). However, the one-component concept of autonomy is problematic in the context of multiple chronic conditions. Adherence to complex treatments commonly breaks down when patients have functional, educational, and cognitive barriers that impair their capacity to plan, sequence, and carry out tasks associated with chronic (...) care. The purpose of this article is to call for a two-component re-conceptualization of autonomy and to argue that the clinical assessment of capacity for patients with chronic conditions should be expanded to include both autonomous decision-making and autonomous execution of the agreed-upon treatment plan. We explain how the concept of autonomy should be expanded to include both decisional and executive autonomy, describe the biopsychosocial correlates of the two-component concept of autonomy, and recommend diagnostic and treatment strategies to support patients with deficits in executive autonomy. (shrink)
This article examines the ethical basis for the patient's duty to adhere to the physician's treatment prescriptions. The article argues that patients have a moral duty to adhere to the physician's treatment prescriptions, once they have accepted treatment. Since patients still retain the right to refuse medical treatment, their duty to adhere to treatment prescriptions is a prima facie duty, which can be overridden by their other ethical duties. However, patients do not have the right to refuse to adhere (...) to treatment prescriptions if their non-adherence poses a significant threat to other people. This paper also discusses the use of written agreements between physicians and patients as a strategy for promoting patient adherence. (shrink)
From an ethical point of view, shared decision-making is preferable to either physician paternalism or patient sovereignty. The traditional model of doctor-patient communication is too directive and too unconcerned with the patient's values to support truly shared decision-making. The traditional distinction between rhetoric and sophistic can provide the basis for a new model of mutual persuasion that does not limit communication to information, and that avoids the spectre of manipulation.
Little attention has been given in medical ethics literature to issues relating to the truthfulness of patients. Beginning with an actual medical case, this paper first explores truth-telling by doctors and patients as related to two prominent models of the physician-patient relationship. Utilizing this discussion and the literature on the truthfulness and accuracy of the information patients convey to doctors, these models are then critically assessed. It is argued that the patient agency (patient autonomy or contractual) model (...) is inherently and seriously flawed in numerous circumstances, even those involving informed and competent adult patients. Keywords: truth-telling, doctor-patient relationship, medical ethics, paternalism, autonomy, patient compliance, patients as agents, informed consent CiteULike Connotea Del.icio.us What's this? (shrink)
The medical profession and medical ethics currently place a greater emphasis on physician responsibility than patient responsibility. This imbalance is not due to accident or a mistake but, rather is motivated by strong moral reasons. As we debate the nature and extent of patient responsibility it is important to keep in mind the reasons for giving a relatively minimal role to patient responsibility in medical ethics. It is argued that the medical profession ought to be characterized by (...) two moral asymmetries: (1) Even if some degree of responsible behavior from patients is called for, placing the dominant emphasis on professional responsibility over patient responsibility is largely correct. The value of protecting the right to refuse treatment and arguments against paternalism block a more expansive account of patient responsibility and support a strong notion of professional responsibility. (2) Insofar as we do want to encourage an increase in patient responsibility, we have good reasons to emphasize prospective rather than retrospective notions of responsibility in clinical practice. Concerns about patient vulnerability along with the determined factors in disease leave little room for blame at the bedside. These two asymmetries generate normative limits on any positive account of patient responsibility. (shrink)
In this paper, I examine the ethics of e - trust and e - trustworthiness in the context of health care, looking at direct computer-patient interfaces (DCPIs), information systems that provide medical information, diagnosis, advice, consenting and/or treatment directly to patients without clinicians as intermediaries. Designers, manufacturers and deployers of such systems have an ethical obligation to provide evidence of their trustworthiness to users. My argument for this claim is based on evidentialism about trust and trustworthiness: the idea that (...) trust should be based on sound evidence of trustworthiness. Evidence of trustworthiness is a broader notion than one might suppose, including not just information about the risks and performance of the system, but also interactional and context-based information. I suggest some sources of evidence in this broader sense that make it plausible that designers, manufacturers and deployers of DCPIs can provide evidence to users that is cognitively simple, easy to communicate, yet rationally connected with actual trustworthiness. (shrink)
Machine generated contents note: ContentsIntroduction: A Change of Heart1. What's behind Animal Advocacy? -- 2. The Love of a Dog: Of Pets and Puppy Mills, Mixed-Breeds and Shelters -- 3. The Animal on Your Plate: Farmers, Vegans, and Locavores -- 4. Where the Wild Things Ought to Be: Sanctuaries, Zoos, and Exotic Pets -- 5. From Object to Subject: Animals in Scientific Research -- 6. Clothing Ourselves in Stories of Love: Affect and Animal AdvocacyConclusion: Trouble in the PackAcknowledgments -- (...) Notes -- Bibliography -- Index. (shrink)
In the latter half of the 20th century, Western medicine moved death from the home to the hospital. As a result, the process of dying seems to have lost its spiritual dimension, and become a matter of prolonging material life by means of medical technology. The novel quandaries that arose led in turn to medico-legal regulation. This paper describes the recent regulation of dying in Israel under its Dying Patient Law, 2005. The Law recognizes advance directives in principle, but (...) limits their effect and form through complex medico-legal artifices. It reflects a culture that places high value on both scientific medicine and the sanctity of life as such, and illustrates a medical culture that pitches battle against death. At the same time, the Law constructs the will of the individual in a medico-legal language that is alien to the lay person. The paper suggests an alternative approach to advance care planning that is patient-centred and addresses the psycho-social needs of the individual in terms of her relational autonomy. From this perspective, advance care planning becomes an opportunity to extract the patient from the medical context and allow her to speak about her approaching death with close ones in her own terms of reference. To this end, there is a need for facilitation of an intimate encounter where patients can speak about their concerns with their loved ones. The paper also presents a methodological approach of attentive listening, which can be applied across diverse cultures and circumstances. (shrink)
The art of interpretation has traditionally been an integral part of medical practice, but little attention has been devoted to its theory. Hermeneutics or the study of interpretation has grown as a methodological interest primarily within the humanities. Borrowing from the medieval fourfold sense of scripture, which organizes interpretive activity both logically and comprehensively, I propose a hermeneutical model of clinical decision-making. According to the model, a patient is analogous to a literary text which may be interpreted on four (...) levels: (1) the literal facts of the patient's body and the literal story told by the patient, (2) the diagnostic meaning of the literal data, (3) the praxis (prognosis and therapeutic decisions) emanating from the diagnosis, and (4) the change effected by the clinical encounter in both the patient's and clinician's life-worlds. The model is illustrated through application to a medical case. (shrink)
In order to protect patients against medical paternalism, patients have been granted the right to respect of their autonomy. This right is operationalized first and foremost through the phenomenon of informed consent. If the patient withholds consent, medical treatment, including life-saving treatment, may not be provided. However, there is one proviso: The patient must be competent to realize his autonomy and reach a decision about his own care that reflects that autonomy. Since one of the most important (...) class='Hi'>patient rights hinges on the patient's competence, it is crucially important that patient decision making incompetence is clearly defined and can be diagnosed with the greatest possible degree of sensitivity and, even more important, specificity. Unfortunately, the reality is quite different. There is little consensus in the scientific literature and even less among clinicians and in the law as to what competence exactly means, let alone how it can be diagnosed reliably. And yet, patients are deemed incompetent on a daily basis, losing the right to respect of their autonomy. In this article, we set out to fill that hiatus by beginning at the very beginning, the literal meaning of the term competence. We suggest a generic definition of competence and derive four necessary conditions of competence. We then transpose this definition to the health care context and discuss patient decision making competence. (shrink)
Hilary Putnam’s influential analysis of the ‘division of linguistic labour’ has a striking application in the area of doctor–patient interaction: patients typically think of themselves as consumers of technical medical terms in the sense that they normally defer to health professionals’ explanations of meaning. It is at the same time well documented that patients tend to think they are entitled to understand lay health terms like ‘sickness’ and ‘illness’ in ways that do not necessarily correspond to health professionals’ understanding. (...) Drawing on recent philosophical theories of concept possession, the article argues that this disparity between medical and lay vocabulary implies that it is, in an important range of cases, easier for doctors to create a communicative platform of shared concepts by using and explaining special medical expressions than by using common lay expressions. This conclusion is contrasted with the view that doctors and patients typically understand each other when they use lay vocabulary. Obviously, use of expressions like ‘sickness’ or ‘illness’ does not necessarily lead to poor communication, but it is important that doctors have an awareness of how patients interpret such terms. (shrink)
Philosophers and physicians alike tend to discuss the physician-patient relationship in terms of physician privilege and patient autonomy, stressing the duty of the physician to respect the autonomy and the variously elaborated rights of the patient. The authors of this article argue that such emphasis on rights was initially productive, in a first generation of debate on medical ethical issues, but that it is now time for a second generation effort that will stress the importance of the (...) unique experiential aspects of the physician-patient relationship — mutual trust, suffering and healing. We attempt here to initiate this second-generation discussion, presenting the first generation's philosophical background, criticizing it from the perspective of clinical experience, and seeking a synthesis in the relational qualities of patient and physician interacting in a medical context. (shrink)
Physicians make some medical decisions without disclosure to their patients. Nondisclosure is possible because these are silent decisions to refrain from screening, diagnostic or therapeutic interventions. Nondisclosure is ethically permissible when the usual presumption that the patient should be involved in decisions is defeated by considerations of clinical utility or patient emotional and physical well-being. Some silent decisions - not all - are ethically justified by this standard. Justified silent decisions are typically dependent on the physician's professional judgment, (...) experience and knowledge, and are not likely to be changed by patient preferences. We condemn the inappropriate exclusion of the patient from the decision-making process. However, if a test or treatment is unlikely to yield a net benefit, disclosure and discussion are at times unnecessary. Appropriate silent decisions are ethically justified by such considerations as patient benefit or economy of time. (shrink)
Patient-Centered Care and Cultural Practices: Process and Criteria for Evaluating Adaptations of Norms and Standards in Health Care Institutions Content Type Journal Article Pages 327-339 DOI 10.1007/s10730-009-9115-8 Authors Matthew R. Hunt, McMaster University Department of Clinical Epidemiology and Biostatistics Montreal Canada Journal HEC Forum Online ISSN 1572-8498 Print ISSN 0956-2737 Journal Volume Volume 21 Journal Issue Volume 21, Number 4.
Kathy Rudy: Loving Animals: Toward a New Animal Advocacy Content Type Journal Article Category Book Review Pages 1-4 DOI 10.1007/s10806-011-9354-y Authors Anna Peterson, Department of Relilgion, University of Florida, Gainesville, FL, USA Journal Journal of Agricultural and Environmental Ethics Online ISSN 1573-322X Print ISSN 1187-7863.
The purpose of this paper is to evaluate the significance of the existential notion of authenticity for medical ethics. This is done by analyzing authenticity and examining its implications for the patient-professional relationship and for ethical decision-making in medical situations. It is argued that while authenticity implies important demand for individual responsibility, which has therapeutic significance, it perpetuates ideas which are antithetical both to authentic interaction between patients and professionals and to fruitful deliberation of moral dilemmas. In order to (...) counteract these consequences, an alternative idea of authenticity is introduced. According to this idea, authenticity is not regarded primarily as individual sovereignty, but as an ability to participate in a dialogue in which the subjectivity of both partners is respected. Such practice, based on mutual trust and responsibility, would enhance common decision-making and overcome the alienation between patients and professionals. (shrink)
It is common to talk of wise physicians, but not so common to talk of wise patients. "Patient" is a word derived from the Latin patior - "to suffer," but also "to let be." Suffering has been the universal lot of humanity, and medicine rightly tries to relieve suffering. Medical progress, like all technological progress, leads us more and more to hope that we can control our fate. However, we do well to ask whether our attempts to control our (...) fate are wise. Wisdom played a major role in the philosophy of the ancient Stoics, and so I propose putting these questions into the context of a new stoicism. For the Stoic, happiness consists in living in accord with nature. Stoics are sometimes portrayed as apathetic fatalists, silently accepting whatever misfortune might come their way, but this is a misunderstanding. The Stoic sage, like the common person, wants to preserve life and health. The difference is that the sage's wisdom brings knowledge about what actions are appropriate in the face of suffering. The sage sees suffering not as something that demands immediate control, but as something that might reasonably direct actions. Suffering brings turmoil to the common patient, who will take any possible steps to end the suffering. The wise patient possesses the knowledge that enables a correct assessment of the options in the face of the reality that we ultimately do not control our own fate. (shrink)
Considering Pragma-Dialectics honors the monumental contributions of one of the foremost international figures in current argumentation scholarship: Frans van Eemeren. The volume presents the research efforts of his colleagues and addresses how their work relates to the pragma-dialectical theory of argumentation with which van Eemeren’s name is so intimately connected. This tribute serves to highlight the varied approaches to the study of argumentation and is destined to inspire researchers to advance scholarship in the field far into the (...) future. Replete with contributions from highly-esteemed academics in argumentation study, chapters in this volume address such topics as: *Pragma-dialectic versus epistemic theories of arguing and arguments; *Pragma-dialectics and self-advocacy in physician-patient interactions; *The pragma-dialectical analysis of the ad hominem family; *Rhetoric, dialectic, and the functions of argument; and *The semantics of reasonableness. As an exceptional volume and a fitting tribute, this work will be of interest to all argumentation scholars considering the astute insights and scholarly legacy of Frans van Eemeren. (shrink)
The paper looks in detail at patients that were treated at one of the most discussed companies operating in the field of untried stem cell treatments, Beike Biotech of Shenzhen, China. Our data show that patients who had been treated at Beike Biotech view themselves as proactively pursuing treatment choices that are not available in their home countries. These patients typically come from a broad variety of countries: China, the United Kingdom, the United States, South Africa and Australia. Among the (...) patients we interviewed there seemed to be both an awareness of the general risks involved in such experimental treatments and a readiness to accept those risks weighed against the possible benefits. We interpret this evidence as possibly reflecting the emergence of risk-taking patients as ‘consumers’ of medical options as well as the drive of patients to seek treatment options in the global arena, rather than being hindered by the ethical and regulatory constraints of their home countries. Further, we found that these patients tend to operate in more or less stable networks and groups in which they interact and cooperate closely and develop opinions and assessments of available treatment options for their ailments. These patients also perform a multiple role as patients, research subjects, and research funders because they are required to pay their way into treatment and research activities. This new social dynamics of patienthood has important implications for the ethical governance of stem cell treatments. (shrink)
Currently, the common theoretical models of "preferred" decision-making relationships do not correspond well with clinical experience. This interview study of congestive heart failure (CHF) patients documents the variety of patient preferences for decision-making, and the necessity for attention to family involvement. In addition, these findings illustrate the confusion as to the designation of surrogate decision-makers and physicians in charge. We conclude that no single model of physician-patient decision-making should be preferred, and that physicians should first ask patients how (...) they want medical information and decision-making to be handled. (shrink)
The U.S. Supreme Court's seminal 1978 Bakke decision, now 25 years old, has an ambiguous and endangered legacy. Justice Lewis Powell's opinion provided a justification that allowed leaders in medical education to pursue some affirmative action policies while at the same time undermining many other potential defenses. Powell asserted that medical schools might have a "compelling interest" in the creation of a diverse student body. But Powell's compromise jeopardized affirmative action since it blocked many justifications for responding to increases (...) in political opposition and legal challenges. The Bakke decision and itsmoral background and legal legacy are traced and analyzed. Despite recent legal setbacks, the framework sketched by Powell can be used to defend diversity inmedical education bothmorally and legally as a "compelling state interest." Because trust is a central component of the physician-patient relationship and a prerequisite to the profession's ability to provide effectivemedical care, the state has a compelling interest in training physicians with whom patients can feel comfortable and safe if the population is (1) distrustful; (2) underserved; (3) faces significant discrimination in the allocation of benefits, goods and services and (4) affirmative action programs would be likely to promote their trust in the system. Similar narrowly-tailored arguments could be used in other professions and for other groups. Bakke is an important background for the pending Grutter case. (shrink)
In this issue of the Report, Daniel Groll suggests new ways to understand old tensions between autonomy and paternalism. He categorizes disagreements between doctors and patients in four ways. Some are about the ends or goals of medical treatment. For these, he claims, patient choices are based upon patient values, and physicians should neither challenge nor assess them. More common are disagreements about the appropriate means to achieve an agreed-upon goal. These subdivide into two distinct categories—those in which (...) the relative efficacy of possible means is “medically assessable” and those in which it is not. When disagreements are medically assessable, Groll argues, doctors can legitimately challenge patient .. (shrink)
The notion that the family is the unit of care for family doctors has been enigmatic and controversial. Yet systems theory and the biopsychosocial model that results when it is imported into medicine make the family system an indispensable and important component of family medicine. The challenge, therefore, is to provide a coherent, plausible account of the role of the family in family practice. Through an extended case presentation and commentary, we elaborate two views of the family in family medicine (...) — treating the patient in the family and treating the family in the patient — and defend both as appropriate foci for care by family doctors. The practical problem that arises when the family is introduced into health care is deciding when to concentrate on the family system. The moral problems that arise concern how extensively doctors may become involved in the personal lives of their patients and families. The patient-centered clinical method provides a strategy for handling both problems. Thus, making the family a focus of care in family medicine can be justified on theoretical, practical, and moral grounds. (shrink)
The rule that a patient should give a free, fully-informed consent to any therapeutic intervention is traditionally thought to express merely a right of the patient against the physician, and a duty of the physician towards the patient. On this view, the patient may waive that right with impugnity, a fact sometimes expressed in the notion of a right not to know. This paper argues that the rule also expresses a duty of the patient towards (...) the physician and a right of the physician against the patient. The argument turns, first, on the truism that a physician has no obligation to commit a battery, or unauthorized touching, and, second, on the thesis that a patient necessarily cannot consent to something that is unknown to him. The conclusion is drawn that a patient is not free to receive treatment voluntarily without knowledgeably authorizing it. CiteULike Connotea Del.icio.us What's this? (shrink)
In the case of an intellectually disabled patient, the attending physician was restricted from writing a Do-Not-Resuscitate (DNR) order. Although the rationale for this restriction was to protect the patient from an inappropriate quality of life judgment, it resulted in a worse death than the patient would have experienced had he not been disabled. Such restrictions that are intended to protect intellectually disabled patients may violate their right to equal treatment and to a dignified death.
A common financial model used in business decisions is the cost/benefit comparison. The costs of a proposed project are compared with the benefits, and if the benefits outweigh the costs, the project is accepted; if the costs exceed the benefits, the project is rejected. This model is applicable when tangible costs and benefits can be reasonably measured in monetary units. However, it is difficult to consider intangible factors in this model because intangible factors cannot be readily quantified in money.While some (...) might argue that the financial model should not apply to healthcare decisions, the fact is that costs do enter into the picture. People may decide to forego needed healthcare because they cannot afford it. Healthcare providers may make choices based in part on the costs of diagnosis and treatment, rather than solely on medical information and what is best for the patient. Should financial issues enter into healthcare decisions – decisions about human health and well being? If so, how should the costs and benefits be measured and evaluated? What are some ethical issues and dilemmas involved in such decisions? (shrink)
Patient autonomy, as exercised in the informed consent process, is a central concern in bioethics. The typical bioethicist's analysis of autonomy centers on decisional capacity—finding the line between autonomy and its absence. This approach leaves unexplored the structure of reasoning behind patient treatment decisions. To counter that approach, we present a microeconomic theory of patient decision-making regarding the acceptable level of medical treatment from the patient's perspective. We show that a rational patient's desired treatment level (...) typically departs from the level yielding an absence of symptoms, the level we call ideal. This microeconomic theory demonstrates why patients have good reason not to pursue treatment to the point of absence of physical symptoms. We defend our view against possible objections that it is unrealistic and that it fails to adequately consider harm a patient may suffer by curtailing treatment. Our analysis is fruitful in various ways. It shows why decisions often considered unreasonable might be fully reasonable. It offers a theoretical account of how physician misinformation may adversely affect a patient's decision. It shows how billing costs influence patient decision-making. It indicates that health care professionals' beliefs about the ‘unreasonable’ attitudes of patients might often be wrong. It provides a better understanding of patient rationality that should help to ensure fuller information as well as increased respect for patient decision-making. (shrink)
Researchers, investigative journalists, community physicians, ethicists, and policy makers have voiced strong concerns about the integrity of medicine. Specifically, questions have been raised about the ways in which financial conflicts of interest (FCOI) in the biomedical field may be compromising the integrity of the scientific research process and thus compromising patient care by disseminating imbalanced or even inaccurate information (Angell 2004). Indeed, many of us are no longer surprised when we read about settlements made by pharmaceutical companies—some totaling hundreds (...) of millions of dollars—for withholding information on adverse side effects, overstating the efficacy of medications, or for aggressive .. (shrink)
Accidental human immunodeficiency virus (HIV) infection of patients in health care settings raises the question about whether patients have a right to expect disclosure of HIV/AIDS diagnoses by their health workers. Although such a right – and the correlative duty to disclose – might appear justified by reason of standards of informed consent, I argue that such standards should only apply to questions of risks of and barriers to HIV infection involved in a particular medical treatment, not to disclosure of (...) personal diagnoses. Because the degree of risk of HIV infection is low and disclosure would also have damaging consequences for health workers, and because patient protection is available in other ways, it is argued that no such generalized right should be recognized. Keywords: duty to disclose, HIV infection, HIV/AIDS diagnosis, informed consent, right to know CiteULike Connotea Del.icio.us What's this? (shrink)
Cancer would be better, I shouldn't say that, because I don't think it would be better. But it would be easier to share with somebody. I think I could tell somebody I had cancer, that I was dealing with cancer, I can't tell people about this, because, first of all, I don't know what to call it. I don't know how to describe it. Chronic fatigue syndrome? People have never heard of such a thing! It doesn't mean anything to them! (...) It doesn't sound real.The phrase "patient complains of …" in the title of this paper is taken from the language commonly used by American physicians when describing the patient's self-reporting of symptoms. In the epigraph above, the patient is describing a situation in which a physician has .. (shrink)
Theoretical models for patient-physician communication in clinical practice are frequently described in the literature. Respecting patient autonomy is an ethical problem the physician faces in a medical emergency situation. No theoretical physician-patient model seems to be ideal for solving the communication problem in clinical practice. Theoretical models can at best give guidance to behavior and judgement in emergency situations. In this article the premises of autonomous treatment decisions are discussed. Based on a case-report we discuss different genuine (...) efforts the physician can do to uncover treatment refusal and respect patient autonomy in an emergency situation. Autonomy requires competence and in emergency medicine time does not allow intimate exploration of patient competence and reasons for treatment refusal. We find that the physician must base her decision on a firm theoretical base combined with a practical and realistic view of the patient's situation on a case to case basis. (shrink)
Despite its virtues, lay decision-making in medicine shares with professional decision-making a disturbing common feature, reflected both in formal policies prohibiting high-risk research and in informal policies favoring treatment decisions made when a crisis or change of status occurs, often late in a downhill course. By discouraging patient decision-making but requiring dedication to the patient's interests by those who make decisions on the patient's behalf, such practices tend to preclude altruistic choice on the part of the (...) class='Hi'>patient. This eclipse is to be regretted not just because widescale altruism has the capacity to provide important social goods and correct injustices in distribution, but for intrinsic reasons as well. It is argued that preserving the possibility of altruism obliges patients – and future patients – to make decisions about dying and other medical matters in advance, thus avoiding that displacement of decision-making onto lay and professional second parties which results in altruism's eclipse. Keywords: altruism, medical decision-making, patient's interest, self-interest, autonomy, death and dying decisions, refusal of treatment, prolongation of life, allowing to die, high-risk research CiteULike Connotea Del.icio.us What's this? (shrink)
When a patient fails to follow the advice or prescription of a physician, she is termed to be "noncompliant" by the medical community. The medical community’s response to and understanding of patient noncompliance fails to acknowledge noncompliance as either a relational failure between physician and patient or as a patient choice. I offer an analysis of Immanuel Kant and Emmanuel Levinas that refocuses the issue of noncompliance by examining the physician role, the doctor–patient relationship, and (...) the nature of responsibility. (shrink)
Theoretical models for physician-patient communication in clinical practice are described in literature, but none of them seems adequate for solving the communication problem in clinical practice that emerges in case of factitious disorder. Theoretical models generally imply open communication and respect for the autonomy of the patient. In factitious disorder, the physician is confronted by lies and (self)destructive behaviour of the patient, who in one way or another tries to involve the physician in this behaviour. It is (...) no longer controversial that the physician should communicate his consideration of a factitious disorder without insistence that the patient accepts this diagnosis. However, the balance between patient autonomy and open communication on the one hand, and the preservation of the patient's health, physician integrity and of a constructive physician-patient relationship on the other is easily disrupted. In this article, an epistemological model is described to facilitate a positive outcome of confrontation in treatment of factitious disorder. Analysing the problem in terms of systems theory will help the physician to assess what information is appropriate to use in which phase of the patient's treatment, while preserving the physician-patient relationship. (shrink)
Stiff Person Syndrome (SPS) is a rare autoimmune disorder associated with antibodies against glutamic acid decarboxylase (GAD-Ab), the key enzyme in γ -aminobutyric acid synthesis (GABA). In order to investigate the role of cerebral benzodiazepinereceptor binding in SPS, we performed [ 11 C]flumazenil (FMZ) positron emission tomography (PET) in a female patient with SPS compared to nine healthy controls. FMZ is a radioligand to the postsynaptic (...) central benzodiazepine receptor which is co-localized with the GABA-A receptor. In the SPS patient, we found a global reduction of cortical FMZ binding. In addition, distinct local clusters of reduced radiotracer binding were observed. These data provide first in vivo evidence for a reduced postsynaptic GABA-A receptor availability which may reflect the loss of GABAergic neuronal inhibition in SPS. (shrink)
How is a terminally ill patient treated by the surrounding people in the U.S. and Japan? How does a terminally ill patient decide on his or her own treatment? These questions will be examined in a study of intensive medical care, received by a terminally ill Japanese cancer patient in the U.S. and Japan. This casereflects the participant observation by a Japanese anthropologist for about 8 years in the United States and Japan on one patient who (...) was hospitalized in both countries on and off for about eight years. The objective of this study is to illuminate the different concept of personhood between the U.S. and Japan that appeared in different cultural practices of both countries and in the subject’s own decision making process. The significant differences appeared between theU.S. and Japan in the concepts of (1) science, (2) suffering, (3) Power of Attorney and Doisho (Consent Form), and (4) organized care. The interpretation of such differences indicates that seemingly universal practices across countries suggest cultural specific concepts and their management. Therefore, ethical norms appeared differently accordingly to each country. (shrink)
The primary purpose of this cross sectional study was to empirically test the notion that retail pharmacists' moral reasoning scores (using Rest's Defining Issues Test) relate to their patient care performance scores (using the Behavioral Pharmaceutical Care Scale). Presently, retail pharmacy organizations are experiencing a paradigm shift from a prescription dispensing emphasis to a patient-centered one. The present investigation examined the influence of moral reasoning, within the situational context of workload pressures and perceived normative beliefs of significant others, (...) on retail pharmacists' self-report patient care performance scores.A secondary goal was to explore the relationship between moral reasoning and retail pharmacists' propensity to exaggerate depictions of their true behavior (using a short-form Marlowe-Crowne Social Desirability Scale). (shrink)