We all know that doctors accept gifts from drug companies, ranging from pens and coffee mugs to free vacations at luxurious resorts. But as the former Editor-in-Chief of The New England Journal of Medicine reveals in this shocking expose, these innocuous-seeming gifts are just the tip of an iceberg that is distorting the practice of medicine and jeopardizing the health of millions of Americans today. In On the Take, Dr. Jerome Kassirer offers an unsettling look at the pervasive payoffs that (...) physicians take from big drug companies and other medical suppliers, arguing that the billion-dollar onslaught of industry money has deflected many physicians' moral compasses and directly impacted the everyday care we receive from the doctors and institutions we trust most. Underscored by countless chilling untold stories, the book illuminates the financial connections between the wealthy companies that make drugs and the doctors who prescribe them. Kassirer details the shocking extent of these financial enticements and explains how they encourage bias, promote dangerously misleading medical information, raise the cost of medical care, and breed distrust. Among the questionable practices he describes are: the disturbing number of senior academic physicians who have financial arrangements with drug companies; the unregulated "front" organizations that advocate certain drugs; the creation of biased medical education materials by the drug companies themselves; and the use of financially conflicted physicians to write clinical practice guidelines or to testify before the FDA in support of a particular drug. A brilliant diagnosis of an epidemic of greed, On the Take offers insight into how we can cure the medical profession and restore our trust in doctors and hospitals. (shrink)

Due to society's need to control health care costs and to the failure of legislated health care reform, managed care is expanding at a rapid rate and will soon be the predominate form of health care delivery. Plans by Congress to bring Medicare and Medicaid under managed care will further consolidate this trend. Barring some legislative fiat, managed care is here to stay.The term managed care describes a diverse set of organizational forms. Wide variations in approach, financing, physician (...) involvement, and philosophy exist among the different types of managed care organizations. While many articles on the ethics of managed care acknowledge this variety, most analyses focus on the for-profit entities, paying less attention to the ethical distinctions among the different forms of managed care. This paper discusses the key distinctions among MCO types, in particular the difference between for-profit and non-profit plans; the relationship of the physician to the MCO; the incentives used to control costs; the incentives that improve patient care; and the organizational features that nurture the principled practice of medicine. (shrink)

Due to society's need to control health care costs and to the failure of legislated health care reform, managed care is expanding at a rapid rate and will soon be the predominate form of health care delivery. Plans by Congress to bring Medicare and Medicaid under managed care will further consolidate this trend. Barring some legislative fiat, managed care is here to stay. The term managed care describes a diverse set of organizational forms. Wide variations in approach, financing, (...) class='Hi'>physician involvement, and philosophy exist among the different types of managed care organizations. While many articles on the ethics of managed care acknowledge this variety, most analyses focus on the for-profit entities, paying less attention to the ethical distinctions among the different forms of managed care. This paper discusses the key distinctions among MCO types, in particular the difference between for-profit and non-profit plans; the relationship of the physician to the MCO; the incentives used to control costs; the incentives that improve patient care; and the organizational features that nurture the principled practice of medicine. (shrink)

Medical ethics has become an important and recognized component of physician training. There is one area, however, in which medical students receive little guidance. There is practically no discussion of the financial aspects of medical practice. My objective in this paper is to initiate a discussion about the moral dimension of physician billing practices. I argue that physicians should expand their conception of professional responsibility in order to recognize that their moral obligations toward patients include a commitment to (...) honest and forthright billing practices. I argue that physicians should aspire to a standard of clinical accuracy—not legal adequacy—in describing their activities. More generally, physicians should strive to promote an integrity-based professional culture, first and foremost by stigmatizing rather than celebrating creative billing practices, as well as condemning the misguided sense of solidarity that currently makes it taboo for physicians to criticize each other on this score. (shrink)

The increased competition for a share of the market of insured patients, which arose in the wake of failed comprehensive health care reform, has provoked questions about what, if any, standards will govern new “competitive” health care organizations. Managed care arrangements, which typically shift to providers and patients some or all of the financial risk for patient care, are of special concern because they can create incentives to withhold beneficial care from patients. Of course, fee-for-service medical practice creates incentives to (...) provide unnecessary services, and managed care can avoid that type of harm. Still, as Edmund Pellegrino has noted, “managed care, by its nature, places the good of the patient into conflict with … the good of all the other patients served by the plan; the good of the plan and the organization, themselves…; and the self-interest of the physician. (shrink)

The increased competition for a share of the market of insured patients, which arose in the wake of failed comprehensive health care reform, has provoked questions about what, if any, standards will govern new “competitive” health care organizations. Managed care arrangements, which typically shift to providers and patients some or all of the financial risk for patient care, are of special concern because they can create incentives to withhold beneficial care from patients. Of course, fee-for-service medical practice creates incentives to (...) provide unnecessary services, and managed care can avoid that type of harm. Still, as Edmund Pellegrino has noted, “managed care, by its nature, places the good of the patient into conflict with … the good of all the other patients served by the plan; the good of the plan and the organization, themselves…; and the self-interest of the physician. (shrink)

Advance care planning (ACP) is a process that seeks to elicit patients’ goals, values, and preferences for future medical care. While most commonly employed in adult patients, pediatric ACP is becoming a standard of practice for adolescent and young adult patients with potentially life-limiting illnesses. The majority of research has focused on patients and their families; little attention has been paid to the perspectives of healthcare providers (HCPs) regarding their perspectives on the process and its potential benefits and limitations. Focus (...) groups were conducted with 15 physicians as part of a larger study of adolescent and young adult ACP in hematopoietic stem cell transplant (HSCT) patients. This study identified two categories important to the utility of ACP in pediatric HSCT patients; (1) the temporal context of ACP and decision making and (2) the limitations of pediatric ACP, with subcategories identified as (a) embodied and witnessed knowing, (b) the impact of clinical cascades—when the treatment of one organ system creates complications in another system that needs to be treated—and a creation of a “new normal” following complications of illness and its treatment in the pediatric intensive care unit (PICU), (c) the balancing of adolescents’ autonomy with their capacity to make informed medical decisions, and (d) the epistemological frames that differ between HCP and patients and their families. These findings support ACP in adolescent and young adult HSCT patients, with a number of implications for practice as this process becomes more common. (shrink)

Each country may face some distinctive ethical problems. Little is known about what kind of ethical problems exist and how often physicians are faced with them in clinical settings in Japan. The authors conducted both retrospective and prospective studies to identify ethical dilemmas at a general medical ward of a university hospital in Japan. In the first phase of the study, retrospective chart reviews were conducted for 61 patients who had been admitted to our general medical ward. It revealed that (...) ethical dilemmas were recorded in 17 cases. In the subsequent period, as the second phase of the study, 6-month prospective case findings were conducted, showing that 22 of 47 patients had ethical dilemmas that attending physicians were concerned about. Ethical dilemmas frequently identified included refusal of or unnecessary requests for diagnostic procedures or treatment by patients, issues concerning truth-telling to patients with a serious illness, and disagreement regarding plans for patient care between patients' family and physicians in charge. The prospective case findings identified a significantly higher frequency of ethical dilemmas than did retrospective chart reviews . Demographics were not significantly different for the two patient groups. The data suggests that ethical dilemmas are not uncommon in general medical wards in Japan. The patients' family played a significant role in clinical decision making, leading on some occasions to complicated ethical dilemmas. (shrink)

We draw on the behavioral agency model to explore the ethical consequences of CEO equity incentives. We argue that CEOs are more concerned with funding pension plans when they have more to gain from their stock options yet will increasingly underfund employee pension funds as their current option wealth increases. Our findings reveal that both effects hold when the CEO has greater power (also occupying board chair) over firm decision making. Our study suggests that there is an ethical dimension (...) to equity incentives, given they are intended to align CEO interests with shareholders, yet potentially incentivize CEO behaviors with adverse consequences for employees. Insights from our findings provide boards and regulators with behavioral levers to protect employee well-being in the context of pension funding. (shrink)

The paper reviews the discussion within transplantation medicine about the organ supply and demand problem. The focus is on the evolution of attitudes toward compensation plans from the early 1980s to the present. A vehement rejection on ethical grounds of anything but uncompensated donation—once the professional norm—has slowly been replaced by an open debate of plans that offer financial rewards to persons willing to have their organs, or the organs of deceased kin, taken for transplantation. The paper asks (...) how this shift has occurred and what it tells us about the dynamics of bioethical debates, both within professional circles and in wider public arenas. (shrink)

Now I know why so many stories have been written with the theme: “everything changed in one moment.” More than 1,000 days have come and gone, and I still remember one Sunday morning and still follow and feel the effects of one decision.

On December 7, 1994, the U.S. District Court of the Northern District of Illinois ruled that ERISA preempts a participant in an ERISA plan from suing the plan's administrator under a state common law theory of respondeat superior ) : at 208). On September 12, 1995, the Seventh Circuit of the U.S. Court of Appeals reversed this decision and ordered that the case be tried in state court ). The court held that the case had been improperly removed to federal (...) court. The court of appeals stated that the federal court did not have jurisdiction because the plaintiff's claim did not fall within ERISA's provisions.In this case, plaintiff David Rice brought a medical malpractice suit against two doctors who provided treatment to him in accordance with his ERISA insurance plan. (shrink)

Physicians and families need to interact more meaningfully to clarify the values and preferences at stake in advance care planning. The current use of advance directives fails to respect patient autonomy. This paper proposes using the family covenant as a preventive ethics process designed to improve end-of-life planning by incorporating other family members—as agreed to by the patient and those family members—into the medical care dialogue. The family covenant formulates advance directives in conversation with family members and with the assistance (...) of a physician, thereby making advance directives more acceptable to the family, and more intelligible to other physicians. It adds the moral force of a promise to the obligation of respecting a patient’s preferences about end-of-life care. These negotiations between patient, family, and physician, from early planning phases through implementation, should greatly reduce the incidence of family disagreements on what the patient would have wanted. The family covenant ensures advance directive discussions within the family, promotes and respects the autonomy of other family members, and might even spur others in the family to complete advance directives through additional covenants. The family covenant holds the potential to transform moral quagmires into meaningful moral conversation. J Am Geriatr Soc 51:1155–1158, 2003. (shrink)

Over the past 5 years, a series of articles in leading American newspapers has revealed the extent to which the conduct of clinical trials may be affected by inducements offered by corporate research sponsors and accepted by some unscrupulous physicians. The cases described were disturbing. They involved physicians engaged in excessive “enrollment activities” in exchange for money. Some of these physicians perpetrated fraud, falsifying their recruitment records in order to increase their profits. Others ignored exclusion criteria designed to ensure the (...) safety of subjects and the validity of research results, referring their patients to research investigating treatments for conditions from which they did not suffer. One of the articles reports that physicians focusing exclusively on commercial research regularly divulge annual incomes upwards of $1,000,000 with profits in excess of $300,000. Two physicians accumulated well over $10,000,000 through clinical trials activities in less than a decade. (shrink)

For methodological or other legitimate reasons it may sometimes be advantageous to withhold an incentive from research participants who don’t meet certain conditions. This commentary describes a case in which the researchers propose such a plan. The IRB reviewers object to the plan, claiming that it exacts a penalty against participants’ right to withdraw, and that it exerts an undue influence on their continued participation. Each of these arguments is critically evaluated and found unpersuasive.

Hospital ethics committees (HECs) have historically been instituted top-down, often ignoring the needs of the professionals and patients who might use their services. Seventy-four physicians and 123 nurses participated in a hospital-wide needs assessment designed to [1] identify their perceptions of the functions of the HEC, [2] determine which services and educational programs were most desired, and [3] explore which forums were most preferred for discussion of ethical problems. Results indicated that utilization of the HEC focused around five areas of (...) concern: withdrawing/withholding treatment, rationing and control of health care, children's rights, role of the patient and family in decisionmaking, and disagreements about treatment. Physicians and nurses differed widely in their attitudes. Perceptions about the appropriate functions of the HEC strongly influenced decisions regarding which HEC services to use. Needs assessment can play an important role in developing HEC goals and designing programs that meet the needs of professionals. (shrink)

Over the past 5 years, a series of articles in leading American newspapers has revealed the extent to which the conduct of clinical trials may be affected by inducements offered by corporate research sponsors and accepted by some unscrupulous physicians. The cases described were disturbing. They involved physicians engaged in excessive “enrollment activities” in exchange for money. Some of these physicians perpetrated fraud, falsifying their recruitment records in order to increase their profits. Others ignored exclusion criteria designed to ensure the (...) safety of subjects and the validity of research results, referring their patients to research investigating treatments for conditions from which they did not suffer. One of the articles reports that physicians focusing exclusively on commercial research regularly divulge annual incomes upwards of $1,000,000 with profits in excess of $300,000. Two physicians accumulated well over $10,000,000 through clinical trials activities in less than a decade. (shrink)

Individuals can often take steps to preserve or improve their own health. They can eat appropriate quantities of healthy foods, exercise, and refrain from smoking. They can obtain preventive care and adhere to their physicians’ advice about how best to manage their health. But they often fail to take these steps.A widespread failure to adopt healthy behaviors can significantly erode public health while increasing health care costs. Obesity, for example, increases the risk of heart disease, stroke, liver disease, and certain (...) cancers. By one estimate, it is responsible for almost 10 percent of medical spending in the United States, or about $147 billion per year. Smoking increases the risk of heart disease, stroke, lung disease, and cancer; it accounts for nearly 20 percent of deaths each year in the United States and about $96 billion in health care expenditures. (shrink)

The facilitation of tight regulatory frameworks necessary to ensure that new drugs are safe and effective have yet to be effectively applied within the paediatric population. Utilization of unlicensed and off-label drugs in children results in a variety of problems ranging from inefficacy, adverse reactions and in some cases death. This ethically questionable behaviour has led the European government to legally force pharmaceutical companies to propose paediatric applications and carry out clinical studies at early stages of drug development. The new (...) European Paediatric Regulation implemented in 2007 opens a new era of paediatric drug development and will offer the opportunity to vastly improve children's health. However, this brighter outlook for the paediatric community might encourage potentially unethical behaviour in a pharmaceutical industry that finds itself in economically unstable times. The article records the gradual evolution of the US Paediatric Exclusivity Plan and the underlying principle of the newly introduced European Paediatric Regulation. It discusses some of the potential drawbacks and detrimental consequences of implementing the new European regulation, and the prospects of avoiding these by critically evaluating the difficulties experienced by the US. (shrink)

Introduction: Pharmaceutical companies offer various gifts to physicians to encourage them to prescribe their products. This collaboration has some negative and positive aspects. Different countries have established guidelines to limit the collaboration and reform such relationships. This study aims to determine the attitude of Bangladeshi medical students towards pharmaceutical gifts, physician-pharmacist collaboration, and associated factors. Methods: An online cross-sectional and correlational study was conducted through email and Google-Forms among Bangladeshi medical students. A total of 435 students from different medical (...) colleges completed the questionnaires in May and June, 2016. Results: Monthly parental income was moderate among the majority of medical students. Less than 16% had a physician or pharmacist parent. Most of the students were taught about medical ethics, but 73% were not taught about the ethics of physician-pharmacist collaboration. About 85% did not have any experience of interaction with marketing representatives. Drug samples and pennotepads were the most appreciated pharmaceutical gifts. Jewelry and gifts costing more than 100 thousand were said to be the least appreciated pharmaceutical gifts. Attitudes towards drug companies and representatives were assessed by fifteen statements. Medical students had a variety of attitudes regarding its ethical justification. Attitudes were correlated with gender, parental income, physician parents, academic years, and having been taught about pharmaceutical collaboration with physicians. Conclusion and Recommendations: medical students should elaborate on ethical reasoning before accepting pharmaceutical gifts. Medical colleges and curriculums should teach them about the interaction. A national guideline may be needed. (shrink)

Background Policies to use financial incentives to encourage healthy behaviour are controversial. Much of this controversy is played out in the mass media, both reflecting and shaping public opinion. Objective To describe UK mass media coverage of incentive schemes, comparing schemes targeted at different client groups and assessing the relative prominence of the views of different interest groups. Design Thematic content analysis. Subjects National and local news coverage in newspapers, news media targeted at health-care providers and popular websites between (...) January 2005 and February 2010. Setting UK mass media. Results The study included 210 articles. Fifteen separate arguments favourable towards schemes, and 19 unfavourable, were identified. Overall, coverage was more favourable than unfavourable, although most articles reported a mix of views. Arguments about the prevalence and seriousness of the health problems targeted by incentive schemes were uncontested. Moral and ethical objections to such schemes were common, focused in particular on recipients such as drug users or the overweight who were already stereotyped as morally deficient, and these arguments were largely uncontested. Arguments about the effectiveness of schemes and their potential for benefit or harm were areas of greater contestation. Government, public health and other health-care provider interests dominated favourable coverage; oppo- sition came from rival politicians, taxpayersÕ representatives, certain charities and from some journalists themselves. Conclusions Those promoting incentive schemes for people who might be regarded as ÔundeservingÕ should plan a media strategy that anticipates their public reception. (shrink)

Advance care planning (ACP) is considered a pivotal aid in the decision‐making process, especially for many people living with dementia, who inevitably will lose the capacity to make decisions at the end of life. In Italy, ACP has been recently regulated by law 219/2017, leading to the investigation of how physicians deal with ACP in dementia. In order to comprehend the perception of physicians who provide care for patients with dementia regarding ACP and to describe their difficulties and needs, this (...) study presents the results of a qualitative research study performed within a local health authority in northern Italy. Data were collected by semi‐structured interviews with 11 physicians dealing with patients with dementia and were analysed using interpretative phenomenological analysis. Four superordinate themes were identified, describing both the difficulties and challenges perceived by physicians in performing shared ACP in their daily activities. This study demonstrates that physicians experience troubles synchronizing the time of shared ACP with the more rapid development of dementia. Results also suggest that further training about communication on ACP is urgently required to ease the implementation of shared ACP. A broader involvement of institutions and other professionals is also important in spreading ACP among healthcare institutions. (shrink)

Background: Patients today interact with physicians, physician groups, and health plans, each of which may follow distinct ethical guidelines.Method: We systematically compared physician codes of ethics with ethics policies at physician group practices and health plans, using the 1998–99 policies of 38 organisations—18 medical associations , nine physician group practices , and 12 health plans —selected using random and stratified purposive sampling. A clinician and a social scientist independently abstracted each document, using a (...) 397-item health care ethics taxonomy; a reconciled abstraction form was used for analysis. This study focuses on ethics policies regarding professional obligation towards patients, resource allocation, and care for the vulnerable in society.Results: A majority in all three groups mention “fiduciary obligations” of one sort or another, but associations generally address physician/patient relations but not health plan obligations, while plans rarely endorse physicians’ obligations of advocacy, beneficence, and non-maleficence. Except for occasional mentions of cost effectiveness or efficiency, ethical considerations in resource allocation rarely arise in the ethics policies of all three organisational types. Very few associations, groups, or plans specifically endorse obligations to vulnerable populations.Conclusions: With some important exceptions, we found that the ethics policies of associations, groups, and plans are narrowly focused and often ignore important ethical concerns for society, such as resource allocation and care for vulnerable populations. More collaborative work is needed to build integrated sets of ethical standards that address the aims and responsibilities of the major stakeholders in health care delivery. (shrink)

Unrepresented patients—people without capacity to make medical decisions who also lack a surrogate decision‐maker—form a large and vulnerable population within the United States health care system. The burden of unrepresentedness has rightly prompted widespread calls for more and better advance care planning, in which still‐healthy patients are encouraged to designate a surrogate decision‐maker and thus avoid the risk of becoming unrepresented. However, we observe that some patients, even with available social contacts and access to adequate advance care planning services, simply (...) decline to name a surrogate decision‐maker. We propose a novel concept of “informed refusal of representation” (“IRR”) to characterize the position held by some such patients, who are often overlooked in prior work on unrepresentedness. We then discuss physicians’ ethical obligations in the face of such a refusal and avenues by which physicians can support patients without surrogates in receiving goal‐concordant care. (shrink)

Conflicts of interest are rampant in the American medical community. Today it is not uncommon for doctors to refer patients to clinics or labs in which they have a financial interest (40% of physicians in Florida invest in medical centers); for hospitals to offer incentives to physicians who refer patients (a practice that can lead to unnecessary hospitalization); or for drug companies to provide lucrative give-aways to entice doctors to use their "brand name" drugs (which are much more expensive than (...) generic drugs). In Medicine, Money and Morals, Marc A. Rodwin draws on his own experience as a health lawyer--and his research in health ethics, law, and policy--to reveal how financial conflicts of interest can and do negatively affect the quality of patient care. He shows that the problem has become worse over the last century and provides many actual examples of how doctors' decisions are influenced by financial considerations. We learn how two California physicians, for example, resumed referrals to Pasadena General Hospital only after the hospital started paying $70 per patient (their referrals grew from 14 in one month to 82 in the next). As Rodwin writes, incentives such as this can inhibit a doctor from taking action when a hospital fails to provide proper service, and may also lead to the unnecessary hospitalization of patients. We also learn of a Wyeth-Ayerst Labs promotion in which physicians who started patients on INDERAL (a drug for high blood pressure, angina, and migraines) received 1000 mileage points on American Airlines for each patient (studies show that promotions such as this have a direct effect on a doctor's choice of drug). Rodwin reveals why the medical community has failed to regulate conflicts of interest: peer review has little authority, state licensing boards are usually ignorant of abuses, and the AMA code of ethics has historically been recommended rather than required. He examines what can be learned from the way society has coped with the conflicts of interest of other professionals --lawyers, government officials, and businessmen--all of which are held to higher standards of accountability than doctors. And he recommends that efforts be made to prohibit and regulate certain kinds of activity (such as kickbacks and self-referrals), to monitor and regulate conduct, and to provide penalties for improper conduct. Our failure to face physicians' conflicts of interest has distorted the way medicine is practiced, compromised the loyalty of doctors to patients, and harmed society, the integrity of the medical profession, and patients. For those concerned with the quality of health care or medical ethics, Medicine, Money and Morals is a provocative look into the current health care crisis and a powerful prescription for change. (shrink)

In 2017, Italy passed a law that provides for a systematic discipline on informed consent, advance directives, and advance care planning. It ranges from decisions contextual to clinical necessity through the tool of consent/refusal to decisions anticipating future events through the tools of shared care planning and advance directives. Nothing is said in the law regarding the issue of physician assisted suicide. Following the DJ Fabo case, the Italian Constitutional Court declared the constitutional illegitimacy of article 580 of the (...) criminal code in the part in which it does not exclude the punishment of those who facilitate the suicide when the decision has been freely and autonomously made by a person kept alive by life-support treatments and suffering from an irreversible pathology, the source of physical or psychological suffering that he/she considers intolerable, but fully capable of making free and conscious decisions. Such conditions and methods of execution must be verified by a public structure of the national health service, after consulting the territorially competent ethics committee. This statement admits, within strict and regulated bounds, physician assisted suicide, so widening the range of end-of-life decisions for Italian patients. Future application and critical topics will be called into question by the Italian legislator. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Kennedy Institute of Ethics Journal 13.1 (2003) 53-64 [Access article in PDF] Incentives for Providing Organs Patricia Milmoe McCarrick and Martina Darragh After a contentious debate at its 2002 annual meeting, the American Medical Association's House of Delegates voted to endorse the opinion of its Council on Ethical and Judicial Affairs that the impact of financial incentives on organ donation should be studied (Josefson 2002). The shortage of organs (...) for transplantation has been an ongoing problem for more than 20 years. In June1981, Representative Philip Crane (R-IL) introduced legislation in the U.S. House of Representatives proposing a $25,000 income tax deduction and a $25,000 estate tax exclusion for donating an organ (Tax Incentives 1981). Still the National Organ Transplant Act enacted in October 1984 prohibited the offering of any "valuable consideration" in return for organs (United States 1984).The developments of a legal market for tissues in the United States and a black market for organs around the world have raised the question of whether donation without compensation is the only ethically viable option. Some critics of the current system claim reliance on donation actually promotes a black market in organs (Kaserman and Barnett 2002, p. 38; Palmer 1999, p. 36). In addition, a new set of compensation issues has arisen as living kidney donor transplantations begin to rival those performed with cadaveric organs (United States 2001).As a result, current suggestions for incentives go far beyond the traditional death benefit payment to include such ideas as medals of honor for donors, reimbursement for funeral expenses, exchange programs for organ donation, and special medical insurance for living organ donors. Numerous bills introduced into the 107th Congress have proposed such incentives (Delmonico et al. 2002.) In October 2002, the U.S. Department of Health and Human Services awarded $5.2 million in grants to study both clinical and behavioral interventions for increasing organ donations that do not involve incentives. The inspiration for some of the funded proposals comes from the successes of Spain's social services and the United Kingdom's clinical administration of organ procurement programs (Robeznieks 2002). [End Page 53]With a nod to evidence-based medicine, the underlying concern expressed in much of the current literature is that no idea for increasing the supply of organs should be discounted before it is studied. This bibliography provides a short introduction to the range of opinions expressed on the issue of incentives for providing organs.al-Mousawi, M.; Samhan, M.; al-Mezairee I.; Razzak, M.A.; and Khawari, F. Cadaver Organ Procurement in Kuwait. Transplantation Proceedings 31 (8): 3375-76, 1999.The authors describe a protocol that significantly increased cadaveric organ donation and credit it with fostering the expansion of an organ sharing program among the Arab Gulf states. Developed by Kuwaiti neurologists and anesthetists after a continuing education course on transplantation, the protocol places a special emphasis on the role of local transplant coordinators who facilitate the investigation of brain death cases by neurologists.Arnold, Robert; Bartlett, Steven; Bernat, James; et al. [Ethics Committee of the American Society of Transplant Surgeons] Financial Incentives for Cadaver Organ Donation: an Ethical Reappraisal. Transplantation 73 (8): 1361-67, 27 April 2002.To prepare for proposed studies of financial incentives for organ donation, the American Society of Transplant Surgeons convened a panel to develop a methodology for evaluating the ethics of such research. Comprised of organ procurement organization executives, physicians, surgeons, and ethicists, the panel generated a list of nine criteria for use in judging any incentives proposal. While opposed to direct payment or tax incentives for organ donation, a majority of the members support funeral expense reimbursement or charitable contributions as incentives that would not violate or undermine the ideal of altruism.Cameron, J. Stewart, and Hoffenberg, Raymond. The Ethics of Organ Transplantation Reconsidered: Paid Organ Donation and the Use of Executed Prisoners as Donors. Kidney International 55 (2): 724-32, February 1999.After reviewing arguments for and against payment for organ procurement, the authors apply these arguments to the specific case of obtaining organs from executed... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Kennedy Institute of Ethics Journal 13.1 (2003) 51-52 [Access article in PDF] Congress Considers Incentives for Organ Procurement Alexander S. Curtis [Tables]During the 108th Congressional session, several bills pertaining to ethical incentives for organ donation likely will be introduced. In some cases, they will be similar to bills before the 107th Congress (see Table 1). Bills in both the House of Representatives and the Senate address the establishment and (...) maintenance of donor registries, financial reimbursements for medical and nonmedical expenses incurred by qualifying donors, the presentation of commemorative medals, and tax credits.A bill entitled "Gift of Life Congressional Medal Act" (introduced last year by Senate majority leader Bill Frist (R-TN) as Senate Bill 325), and its corresponding bill of the same title (passed in the House of Representatives last year as H.R. 708), would establish a congressional commemorative medal honoring "any organ donor, or the family or family member of any organ donor." The medal is to be designed and struck with "suitable emblems, devices, and inscriptions" by the Secretary of the Treasury. The eligible donor or donor's family member would be presented with the medal by the Secretary of Health and Human Services. This bill would establish qualifying donations as those of human kidneys, livers, hearts, lungs, pancreases, or any other organ, but excludes corneas and eyes.Another bill, introduced by Representative Michael Bilirakis (R-FL) entitled "Organ Donation Improvement Act" (H.R. 624), would award grants or contracts to states, transplant centers, and qualified organ procurement organizations for the purpose of providing travel, subsistence, and incidental nonmedical expenses to individuals who make living donations. In order to receive reimbursement, the donating individuals must reside in states other than the states in which the intended recipients reside and the annual income of those receiving the organs cannot exceed $35,000. The bill also would appropriate $15,000,000 to make grants to states and public and nonprofit entities for the purpose of carrying out studies, public education demonstrations, and outreach activities "designed to increase the number of organ donors within the state." The bill would be effective from time of enactment through 2005. [End Page 51]Two other bills proposed within the House of Representatives in 2002 called for amendment to the Internal Revenue Code. The "Gift of Life Tax Credit Act (introduced as H.R. 1872 by Representative James Hansen (R-UT)) and the "Help Organ Procurement Expand Act" (introduced as H.R. 2090 by Representative Chris Smith (R-NJ)) present a refundable credit to individuals or to the estates of those who agree either to be living donors or to donate their organs upon death. The "Gift of Life Tax Credit Act" refunds $10,000 to the estates of eligible individuals "for the taxable year which includes the date of the individual's death." The "Help Organ Procurement Expand Act" offers a refund of $2,500 to qualified persons. Donations of kidneys, livers, pancreases, islet cells, lungs, and intestines are accepted, however several conditions restrict permissible donors. The "Gift of Life Tax Credit Act" requires that the legally competent individual's death not be due to a suicide and that the intention to donate was clearly declared. The "Help Organ Procurement Expand Act" prohibits donations from individuals who were killed with physician assistance, died as a result of a suicide, have been indicted or convicted of a felony or a misdemeanor offense, or are actively under criminal investigation for a possible felony offense. The "Help Organ Procurement Expand Act" also restricts procuring organs from unborn children or human fetuses and under circumstances in which the living donor would be subject to "unacceptable levels of medical risk of death or permanent debilitation." Alexander S. Curtis is a research assistant at the Kennedy Institute of Ethics, Georgetown University, Washington, DC. He received his bachelor's degree from Miami University.... (shrink)

This book is a comprehensive and unique text and reference in medical ethics. By far the most inclusive set of primary documents and articles in the field ever published, it contains over 100 selections. Virtually all pieces appear in their entirety, and a significant number would be difficult to obtain elsewhere. The volume draws upon the literature of history, medicine, philosophical and religious ethics, economics, and sociology. A wide range of topics and issues are covered, such as law and medicine, (...) truth-telling by the physician, research, population policy, genetics, abortion, dying, and individual rights in medical care. The selections span the centuries, beginning with material from the works of Hippocrates, continuing through Thomas Percival, John Stuart Mill, and Claude Bernard, down to modern commentators like Henry K. Beecher, Walsh McDermott, David L. Bazelon, Paul Freund, H. L. A. Hart, John Rawls, Paul Ramsey, Richard McCormick, Rashi Fein, and Bernard Barber. The text has eight major divisions, beginning with sections on the ethical dimensions of the physician-patient relationship in history; the moral bases of medical ethics; and regulation, compulsion, and protection of the consumer in clinical medicine and public health. Each of these sections includes key essays that appear for the first time. All of the book's major divisions contain primary documents: codes such as the Hippocratic Oath, Medieval Law for the Regulation of Medicine, and the first as well as the most recent code of the American Medical Association; court decisions, including those on Karen Quinlan and on abortion in the United States and West Germany; government documents such as the statement of the National Commission on the Protection of Human Subjects, the Tuskegee Syphilis Report, the British Parliamentary debate on euthanasia, and the Council of Europe on rights of the sick and dying; and various published guidelines such as the Harvard Medical School brain death criteria, the American Hospital Association on patient's rights, and Pope Pius XII on the prolongation of life. Cases that illustrate moral dilemmas are provided for discussion purposes. Each section is preceded by a succinct editor's introduction. The documents and essays are of practical value for practitioners and students in medicine, law, ethics, and counselling, and for individual patients and groups concerned with medical care. Through encompassing divergent viewpoints, the essays and primary documents were selected to encourage humane practices and deepen understanding of the multiple traditions that shaped and do shape the development of medicine. (shrink)

Background The twenty-first century has witnessed an exponential increase in healthcare quality research. As such activities become more prevalent, physicians are increasingly needed to participate as subjects in research and quality improvement (QI) projects. This raises an important ethical question: how should physicians be remunerated for participating as research and/or QI subjects? Financial versus non-monetary incentives for participation Research suggests participation in research and QI is often driven by conditional altruism, the idea that although initial interest in enrolling in research (...) is altruistic or prosocial, decisions to actually perform study tasks are cost–benefit driven. Thus, the three models commonly employed to appropriately compensate participants (in-kind compensation such as travel reimbursement, paying market rates for the subject’s time, and paying market rates for the activity asked of the participant) are a poor fit when the participant is a clinician, largely due to the asymmetry between cost and benefit or value to the participant. Non-monetary alternatives such as protected time for participation, continuing education or maintenance of certification credit, or professional development materials, can provide viable avenues for reducing this asymmetry. Conclusion Research and QI are integral to the betterment of medicine and healthcare. To increase physician participation in these activities as the subject of study, new models are needed that clarify the physician’s role in research and QI as a subject. Non-monetary approaches are recommended to successfully and ethically encourage research and QI participation, and thus incorporate these activities as a normal part of the ethical clinician’s and successful learning healthcare system’s world view. (shrink)

The terrorist attacks of 2001 were a reminder that individual and collective safety cannot be taken for granted. Since then, physicians, alongside public health professionals and other healthcare professionals as well as nonhealthcare personnel, have been developing plans to enhance the protection of public health and the provision of medical care in response to various threats, including acts of terrorism or bioterrorism. Included in those plans are strategies to attend to large numbers of victims and help prevent greater (...) harm to even larger populations. (shrink)

The use of aborted fetal tissues in research and therapy has raised exciting possibilities and a host of social, legal and ethical issues. Perhaps the most difficult issue is whether the use of materials from elective abortion can be viewed and weighed separately from the abortion itself, or if in using these tissues there is inherent complicity with the abortion act. Those who oppose FTT claim that there is complicity with the abortion act and liken the use of fetal tissue (...) from abortions to the use of data from the Nazi experiments. Within this lobby are those who claim that the option to donate fetal tissues will make abortion a more attractive alternative for pregnant women, and that there are doctors who will offer fetal tissue donation as a positive incentive to abortion-with the net effect that more abortions will take place. (shrink)

The use of aborted fetal tissues in research and therapy has raised exciting possibilities and a host of social, legal and ethical issues. Perhaps the most difficult issue is whether the use of materials from elective abortion can be viewed and weighed separately from the abortion itself, or if in using these tissues there is inherent complicity with the abortion act. Those who oppose FTT claim that there is complicity with the abortion act and liken the use of fetal tissue (...) from abortions to the use of data from the Nazi experiments. Within this lobby are those who claim that the option to donate fetal tissues will make abortion a more attractive alternative for pregnant women, and that there are doctors who will offer fetal tissue donation as a positive incentive to abortion-with the net effect that more abortions will take place. (shrink)

In this study, we explore the role of Chief Executive Officers’ incentives, split between monetary and non-monetary, in relation to corporate social responsibility. We base our analysis on a sample of 597 US firms over the period 2005–2009. We find that both monetary and non-monetary incentives have an effect on CSR decisions. Specifically, monetary incentives designed to align the CEO’s and shareholders’ interests have a negative effect on CSR and non-monetary incentives have a positive effect on CSR. The study has (...) important implications for the design of executive remuneration plans, as we show that there are many levers that can affect the CEO’s decisions with regard to CSR. Our evidence also confirms the prominent role of the CEO in relation to CSR decisions, while also recognizing the complexity of factors affecting CSR. Finally, we propose a research design that takes into account endogeneity issues arising when examining compensation variables. (shrink)

: In its response to pressures to rationalize health care resource allocation, the American health care system has embraced managed care without concurrent comprehensive health care reform, either in the form of the centralized tax-based systems found in Europe and Canada or that of the Clinton reform plan. What survives is managed care without managed competition, employer mandates, or universal access. Two problems inherent in the incentive structure of managed care plans developed in the absence of comprehensive health (...) care reform work against the public interest. First, sacrifices in terms of medical innovation and quality of care may not be offset by greater equity in the distribution of health care. Second, such managed care plans fail to address the need for long-term accountability. (shrink)

Increasing geographical mobility and international travel augment the ease and speed by which infectious diseases can spread across large distances. It is therefore incumbent upon each state to ensure that immunisation programmes are effective and that herd immunity is achieved. Across Europe, a range of immunisation policies exist: compulsion, the offer of financial incentives to parents or healthcare professionals, social and professional pressure, or simply the dissemination of clear information and advice. Until recently, immunisation against particular communicable diseases was compulsory (...) in Italy. The Italian National Vaccination Plan paved the way for regions to suspend the sanctions associated with compulsory vaccinations for children when certain criteria are met—for example when immunisation coverage is high and when effective monitoring/surveillance systems are in place—and thus marked a milestone in the move from compulsory to voluntary immunisation. The forthcoming NVP for 2008–10 confirms the liberal approach to vaccination in Italy as it entrusts to the regions responsibility for the achievement and maintenance of herd immunity. This paper reviews the arguments for and against compulsory and voluntary immunisation in relation to the Italian NVP and in the context of the diverse immunisation policies that exist across Europe. It concludes with cautious support for the NVP and an associated shift from compulsory to voluntary immunisation in Italy, and draws similarities between issues concerning regional variation in immunisation policy in Italy and national variation in immunisation policy across Europe and beyond. (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)

The specific issue addressed in this paper is urban encroachment on agricultural lands, and the problems it poses for both analysis and the conservation of the land resource. The purpose of our discussion is two-fold: (1) to identify where and why traditional analytical and regulatory approaches fail to resolve land use conflicts, and (2) to explore ways and means of resolving some of the dilemmas which society faces in making land use decisions. This paper's contribution is in the spirit of (...) Getting Incentives Right for the inter-temporal transfer of wealth, as represented in trade-offs between environmental and resource endowments and human and physical capital. Efforts are placed on identifying what the appropriate price, levy, taxes, and grant ratios ought to be in order to encourage individuals in the marketplace to act in society's interest. We have also explored ways of efficiently transmitting those incentives through the market mechanism, without unduly relying on bureaucratic methods or suasion. Emphasis is placed on mechanisms that have little scope for preferential access and are subject to public scrutiny; emphasis on such self-disciplining approaches should result in less effort expended on (unproductive) lobbying activities and bureaucratic administration. (shrink)

In this discussion paper we consider the influence of ethnicity, religiosity, spirituality and health literacy on Advance Care Planning for older people. Older people from cultural and ethnic minorities have low access to palliative or end-of-life care and there is poor uptake of advance care planning by this group across a number of countries where advance care planning is promoted. For many, religiosity, spirituality and health literacy are significant factors that influence how they make end-of-life decisions. Health literacy issues have (...) been identified as one of the main reasons for a communication gaps between physicians and their patients in discussing end-of-life care, where poor health literacy, particularly specific difficulty with written and oral communication often limits their understanding of clinical terms such as diagnoses and prognoses. This then contributes to health inequalities given it impacts on their ability to use their moral agency to make appropriate decisions about end-of-life care and complete their Advance Care Plans. Currently, strategies to promote advance care planning seem to overlook engagement with religious communities. Consequently, policy makers, nurses, medical professions, social workers and even educators continue to shape advance care planning programmes within the context of a medical model. The ethical principle of justice is a useful approach to responding to inequities and to promote older peoples’ ability to enact moral agency in making such decisions. (shrink)

The use of recent research on variations in medical practice to promote competitive market oriented cost containment strategies is critically examined. Research demonstrating widespread variations in physician practices for similar patient populations undermines the medical profession's claims about the scientific objectivity of medical practice and indicates the existence of widespread waste and inappropriate utilization of health care resources. Cost containment programs which rely on market-based care avoidance incentives, such as Medicare prospective payment or cost sharing plans, attempt to (...) impact medical practice variations by creating economic barriers between doctor and patient. An alternative interpretation of research on practice variations is presented, emphasizing containing costs while improving quality of care and achieving greater equity through planning and regulation of medical supply factors. (shrink)

A training physician has his first interaction with a pharmaceutical representative during medical school. Medical students are often provided with small gifts such as pens, calendars and books, as well as free lunches as part of drug promotion offers. Ethical impact of these transactions as perceived by young medical students has not been investigated in Pakistan before. This study aimed to assess the association of socio-demographic variables with the attitudes of medical students towards pharmaceutical companies and their incentives.