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)

Walton offers a comprehensive, flexible model for physician-patient decision making, the first such tool designed to be applied at the level of each particular case. Based on Aristotelian practical reasoning, it develops a method of reasonable dialogue, a question- and-answer process of interaction leading to informed consent on the part of the patient, and to a decision--mutually arrived at--reflecting both high medical standards and the patient's felt needs. After setting forth his model, he applies it to (...) three vital ethical issues: acts of omission, the cessation of treatment, and possible side effects of treatments. In the final chapter, Walton shows how his method functions in light of the real-life complexities of the clinical encounter and how it bears on ethical questions concerning health-care policy, attitudes toward treatment and toward the medical profession, reasonableness of expectations, and the setting of realistic goals of treatment. (shrink)

Gils-Schmidt and Salloch recognise that human and climate health are inextricably linked, and that mitigating healthcare-associated climate harms is essential for protecting human health.1 They argue that physicians have a duty to consider how their own practices contribute to climate change, including during their interactions with patients. Acknowledging the potential for conflicts between this duty and the provision of individual patient care, they propose the application of Korsgaard’s neo-Kantian account of practical identities to help navigate such scenarios. In this (...) commentary, we argue that by focusing attention on this physician–patient level, the authors overlook the complexity of climate change, both within the healthcare sector and beyond. We recognise the importance of individual agency in tackling this issue, and we also recognise that the authors do briefly acknowledge the importance of considering these broader complexities; however, we emphasise the need for climate and health discussions/action to be situated in a wider framework of systemic change. Our concern is that overemphasis on patient-level interactions risks normalising the prioritisation of individual-level approaches to addressing climate change, detracting from such a broader approach. Physician training emphasises the need for trust, confidentiality and shared decision-making in the doctor–patient relationship. …. (shrink)

Loneliness in medicine is a serious problem not just for patients, for whom illness is intrinsically isolating, but also for physicians in the contemporary condition of medicine. We explore this problem by investigating the ideal physician-patient relationship, whose analogy with friendship has held enduring normative appeal. Drawing from Talbot Brewer and Nir Ben-Moshe, we argue that this appeal lies in a dynamic form of companionship incompatible with static models of friendship-like physician-patient relationships: a mutual refinement of (...) embodied virtue that draws both persons together. The ideal physician-patient relationship has a dialectical character that fosters each member's improvement of phenomenologically recognizing and embodying moral virtues. A key component of this dynamic is a commitment to the common goal of the patient's health, realized through joint interactivities and conversations over time. The physician's presence to the patient's suffering—understood best as an alienating phenomenological condition for the patient—orients and discloses possibilities for virtuous caregiving by structuring the meanings of the goals, conversations, and joint narrative constitutive of their relationship. Presence to suffering, paradoxically, is perhaps an important prerequisite for this dynamic partnership. These activities dialectically build an interpretive horizon of understanding through which moral goods and character refinement—in and for the other—may become revealed for both persons in their shared being-in-the-world. This analysis of suffering, mood, and revealing of (possible) moral goods has implications for addressing the modern problem of loneliness for patients and physicians, who are increasingly inhibited from building flourishing relationships with each other. (shrink)

In this paper, we explore the desires that play a role at the palliative stage and relate them to various approaches to patient autonomy. What attitude can physicians and other caregivers take to the desires of patients at the palliative stage? We examine this question by introducing five physicians who are consulted by Jackie, an imaginary patient with metastatic lung carcinoma. By combining the models of the physician-patient relationship developed by Emanuel and Emanuel (1992) and the (...) Hellenistic approaches to desires analyzed by Nussbaum (1994), five different ways of dealing with desires in the context of palliative care are sketched. The story of Jackie shows that desires are to a certain extent responsive to reasoning. In the palliative process, that can be a reason to devote attention to the desires of patients and caregivers and to determine which desires need to be fulfilled, which are less important, and how they are linked to emotions the patient has. (shrink)

Background The COVID-19 pandemic has influenced the approach to the health-disease system, raising the question about the principles of bioethics present in physician–patient relations. The principles while widely accepted may not be sufficient for a comprehensive ethical analysis. Therefore, the aim of this study was to explore the perception of these principles and the physician–patient relationship during a hospital stay through a qualitative approach. Method Sixteen semi-structured interviews took place to know the patients’ perception during (...) their 2020 hospitalization for COVID-19. The data was analyzed through the constant comparison method, creating categories and comparing them. In the end, seven categories were established and were grouped in three: bioethical principles (dignity, charity, vulnerability, autonomy), doctor-patient relationship (participant commitment, informed consent, health staff-patient relationship) and the experience of the disease (illness, the role of the family). Results The research found that most patients described a positive experience, with the feeling of having been well cared for with no sense of discrimination or injustice done. The majority also reported that their autonomy was respected in the treatment decisions. The evaluation of these attitudes is an area of opportunity, especially when the patients' vulnerability is at risk. Conclusions The ethics of virtue offers a better reflection of how human beings manifest themselves by emphasizing the development of virtuous character and behaviors that allow them to realize their values in life. Authorized by the Research Ethics Committee with registration: DI/18/105-B/3/308. (shrink)

:This article considers recent ethical topics relating to medical AI. After a general discussion of recent medical AI innovations, and a more analytic look at related ethical issues such as data privacy, physician dependency on poorly understood AI helpware, bias in data used to create algorithms post-GDPR, and changes to the patient–physician relationship, the article examines the issue of so-called robot doctors. Whereas the so-called democratization of healthcare due to health wearables and increased access to medical information (...) might suggest a positive shift in the patient-physician relationship, the physician’s ‘need to care’ might be irreplaceable, and robot healthcare workers might be seen as contributing to dehumanized healthcare practices. (shrink)

‘Individualized medicine’ is an emerging paradigm in clinical life science research. We conducted a socio-empirical interview study in a leading German clinical research group, aiming at implementing ‘individualized medicine’ of colorectal cancer. The goal was to investigate moral and social issues related to physician–patient interaction and clinical care, and to identify the points raised, supported and rejected by the physicians and researchers. Up to now there has been only limited insight into how experts dedicated to individualized medicine view (...) its problems. Interviews with researchers and clinicians were based on a prestructured questionnaire. The content analysis revealed a broad spectrum of opinions. Major findings were disappointments with the limits of the current therapy regimen and clinical practice; problematic impacts on physician–patient relationship; and an informed consent procedure which is mainly based on paternalistic assumptions. According to our analysis, major problems will be uncertainties related to the biomarker's sensitivity and specificity, and the identification of ‘non-responders’. However, the findings also indicate that experts expect evidence-based medicine to replace decisions based on gut feeling or hierarchical structures. (shrink)

‘Individualized medicine’ is an emerging paradigm in clinical life science research. We conducted a socio-empirical interview study in a leading German clinical research group, aiming at implementing ‘individualized medicine’ of colorectal cancer. The goal was to investigate moral and social issues related to physician–patient interaction and clinical care, and to identify the points raised, supported and rejected by the physicians and researchers. Up to now there has been only limited insight into how experts dedicated to individualized medicine view (...) its problems. Interviews with researchers and clinicians (n= 19) were based on a prestructured questionnaire. The content analysis revealed a broad spectrum of opinions. Major findings were (a) disappointments with the limits of the current therapy regimen and clinical practice; (b) problematic impacts on physician–patient relationship; and (c) an informed consent procedure which is mainly based on paternalistic assumptions. According to our analysis, major problems will be uncertainties related to the biomarker's sensitivity and specificity, and the identification of ‘non-responders’. However, the findings also indicate that experts expect evidence-based medicine to replace decisions based on gut feeling or hierarchical structures. (shrink)

Acting for the good of the patient is the most fundamental and universally acknowledged principle of medical ethics. However, given the complexity of modern medicine as well as the moral fragmentation of contemporary society, determining the good is far from simple. In his philosophy of medicine, Edmund Pellegrino develops a conception of the good that is derived from the internal morality of medicine via the physician-patient relationship. It is through this healing relationship that rights, duties, and privileges (...) are defined for both physicians and patients. Moreover, this relationship determines the characteristics or virtues that are necessary to engage in the medical telos. This paper addresses the role of the moral virtues in clinical medicine and the physician-patient relationship. First, it provides a brief background of the Aristotelian foundations of virtue-ethics. Second, it delves into Pellegrino’s philosophy of medicine understood as a practice oriented towards a teleological goal. Third, it relates the telos of medicine to the notion of the medical community as a fundamentally moral community. Finally, it concludes with a section that creates a dialogue between virtue ethics and principlism. (shrink)

Empirical studies have now established that many patients make clinical decisions based on models other than Anglo American model of truth-telling and patient autonomy. Some scholars also add that current medical ethics frameworks and recent proposals for enhancing communication in health professional-patient relationship have not adequately accommodated these models. In certain clinical contexts where health professional and patients are motivated by significant cultural and religious values, these current frameworks cannot prevent communication breakdown, which can, in turn, jeopardize (...) class='Hi'>patient care, cause undue distress to a patient in certain clinical contexts or negatively impact his/her relationship with the community. These empirical studies have now recommended that additional frameworks developed around other models of truth-telling; and which take very seriously significant value-differences which sometimes exist between health professional and patients, as well as patient's cultural/religious values or relational capacities, must be developed. This paper contributes towards the development of one. Specifically, this study proposes a framework for truth-telling developed around African model of truth-telling by drawing insights from the communitarian concept of ootọ́ amongst the Yoruba people of south west Nigeria. I am optimistic that if this model is incorporated into current medical ethics codes and curricula, it will significantly enhance health professional-patient communication. (shrink)

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. (shrink)

Medical billing has become so intertwined with patient care, that in order to be truly committed to the physician's telos of managing a patient's medical suffering, it is imperative that physician ought to reexamine many of the ethical considerations about billing.

BackgroundIn the Netherlands, patients have the legal right to make a request for euthanasia to their physician. However, it is not clear what it means in a moral sense for a physician to receive a request for euthanasia. The aim of this study is to explore the moral values of physicians regarding requests for euthanasia. MethodsSemi-structured interviews were conducted with nine primary healthcare physicians involved in decision-making about euthanasia. The data were inductively analyzed which lead to the emergence (...) of themes, one of which was about values regarding end-of-life decisions.ResultsFour clusters of values related to euthanasia requests are described: values related to 1) the patient; 2) the family; 3) the physician; and 4) life and death. The data show that the participants value patient autonomy as a necessary but not sufficient condition for meeting a euthanasia request. A good relationship with the patient and the family are important. For the physician, the values physician autonomy, responsibility, understanding the patient and relief of suffering play a role. Life as an intrinsic good and a peaceful death are also important values.ConclusionThis study shows that next to patient autonomy and the relationship with the patient and the family, it is important for the participants to act in accordance with their professional values and to do justice to values related to life and death. The awareness of going against the intrinsic value of life is crucial, even if performing euthanasia may result in a feeling of relief or gratitude afterwards. (shrink)

ZusammenfassungEin gelungenes Arzt-Patient-Verhältnis, das auf gegenseitigem Vertrauen und ärztlicher Verantwortung basiert, ist ein zentraler Bestandteil des Ideals der ärztlichen Profession. Aktuell wird vielfach von einem neuen „ökonomischen Paradigma“ in der Medizin gesprochen, das dieses Verhältnis vermeintlich unterminiert. Als ein wichtiges Merkmal dieses Paradigmas gilt das Verständnis vom Patienten als Kunden, der charakterisiert ist durch seine Selbstbestimmung bzw. Autonomie. Wie stellt sich die Kundenrolle nun aber bei vulnerablen Patientengruppen dar, die in ihrer Autonomie eingeschränkt sind, und was bedeutet dies wiederum (...) für das Arzt-Patient-Verhältnis? In dem vorliegenden Artikel wollen wir deshalb die Fragestellung verfolgen, ob sich ärztliche Verantwortung bzw. das Arzt-Patient-Verhältnis ändert, wenn sich der (vulnerable) Patient als Kunde begreift. Als Analysesetting dient die Palliativmedizin, da sie als Beispiel für eine besonders vulnerable Patientengruppe gelten kann. Als Basis der Argumentation werden die Ergebnisse einer qualitativen Studie herangezogen, welche die Einstellungen von Palliativpatienten zum Thema „der Patient als Kunde“ erhob sowie der Frage nachging, ob sich Palliativpatienten, speziell im Rahmen von medizinischen Entscheidungen, als selbstbestimmt begreifen. Die Studienergebnisse zeigen, dass Autonomie relational verstanden werden muss und dem Arzt eine entscheidende Rolle in der Ermöglichung von Patientenselbstbestimmung zukommt – ganz unabhängig von der Selbstattribuierung der Befragten als Kunde oder Patient. Anschließend werden diese Ergebnisse dahingehend analysiert, ob sie als Ausdruck einer Veränderung des Arzt-Patient-Verhältnisses und der ärztlichen Verantwortung gegenüber den Patienten zu werten sind. Hieraus folgernd wird nach den praktischen Implikationen für das Arzt-Patient-Verhältnis auf der Grundlage der „Ethics of Care“ gefragt sowie auf die individuelle Betreuungsnotwendigkeit, speziell von vulnerablen Patientengruppen, verwiesen. (shrink)

In November 2003, researchers at Cambridge University announced they had identified a gene associated with an elevated risk of breast and related ovarian cancers. The gene—christened EMSY in honor of a breast-cancer nurse who is the sister of the study's lead author—is particularly significant because it is linked to so-called sporadic cancers. Such cancers do not arise from hereditary mutations of the BRCA1 and BRCA2 genes, in which genes that ordinarily prevent breast and ovarian cancers are altered, often giving rise (...) to multiple cases of cancer within a family as the mutation is passed along. The Cambridge researchers determined that the presence of extra copies of EMSY in an individual may instead switch off a healthy BRCA2 gene. (shrink)

As the price of pharmaceuticals and biologicals rises so does the number of patients who cannot afford them. In this article, we argue that physicians have a moral duty to help patients access affordable medicines. We offer three grounds to support our argument: (i) the aim of prescribing is to improve health and well-being which can only be realized with secure access to treatment; (ii) there is no morally significant difference between medicines being unavailable and medicines being unaffordable, so the (...) steps physicians are willing to take in the first case should extend to the second; and (iii) as the primary stakeholder with a duty to put the individual patient’s interests first, the medical professional has a duty to address cost-barriers to patient care. In articulating this duty, we take account of important epistemic and control conditions that must be met for the attribution of this duty to be justified. (shrink)

Practically every development in medicine in the post–World War II period distanced the physician and the hospital from the patient and the community, disrupting personal connections and severing bonds of trust. We need an ethics that include bodily mediated knowledge as a complement to intellectual knowledge. Care is a challenging concept to explore, in part because it is employed widely and often without thoughtful parsing. Moreover, it has gained increasing significance in ethical discourse.1 Since the 1980s, feminist theorists (...) have used the term care ethics to describe a relational approach to morality that does not rely on rubrics of adjudication such as rules or consequences. The.. (shrink)

Ein gelungenes Arzt-Patient-Verhältnis, das auf gegenseitigem Vertrauen und ärztlicher Verantwortung basiert, ist ein zentraler Bestandteil des Ideals der ärztlichen Profession. Aktuell wird vielfach von einem neuen „ökonomischen Paradigma“ in der Medizin gesprochen, das dieses Verhältnis vermeintlich unterminiert. Als ein wichtiges Merkmal dieses Paradigmas gilt das Verständnis vom Patienten als Kunden, der charakterisiert ist durch seine Selbstbestimmung bzw. Autonomie. Wie stellt sich die Kundenrolle nun aber bei vulnerablen Patientengruppen dar, die in ihrer Autonomie eingeschränkt sind, und was bedeutet dies wiederum (...) für das Arzt-Patient-Verhältnis? In dem vorliegenden Artikel wollen wir deshalb die Fragestellung verfolgen, ob sich ärztliche Verantwortung bzw. das Arzt-Patient-Verhältnis ändert, wenn sich der (vulnerable) Patient als Kunde begreift. Als Analysesetting dient die Palliativmedizin, da sie als Beispiel für eine besonders vulnerable Patientengruppe gelten kann. Als Basis der Argumentation werden die Ergebnisse einer qualitativen Studie herangezogen, welche die Einstellungen von Palliativpatienten zum Thema „der Patient als Kunde“ erhob sowie der Frage nachging, ob sich Palliativpatienten, speziell im Rahmen von medizinischen Entscheidungen, als selbstbestimmt begreifen. Die Studienergebnisse zeigen, dass Autonomie relational verstanden werden muss und dem Arzt eine entscheidende Rolle in der Ermöglichung von Patientenselbstbestimmung zukommt – ganz unabhängig von der Selbstattribuierung der Befragten als Kunde oder Patient. Anschließend werden diese Ergebnisse dahingehend analysiert, ob sie als Ausdruck einer Veränderung des Arzt-Patient-Verhältnisses und der ärztlichen Verantwortung gegenüber den Patienten zu werten sind. Hieraus folgernd wird nach den praktischen Implikationen für das Arzt-Patient-Verhältnis auf der Grundlage der „Ethics of Care“ gefragt sowie auf die individuelle Betreuungsnotwendigkeit, speziell von vulnerablen Patientengruppen, verwiesen. (shrink)

In clinical research – whether pharmaceutical, genetic or biomarker research – it is important to protect research participants’ autonomy and to ensure or strengthen their control over health-related decisions. Empirical–ethical studies have argued that both the ethical concept and the current legalistic practice of informed consent should be adapted to the complexity of the clinical environment. For this, a better understanding of recruitment, for which also the physician–patient relationship plays an important role, is needed. Our aim is to (...) ethically reflect communication processes by identifying patterns used by physicians to motivate patients’ participation in clinical research and to assess whether patients also use these patterns in formulating their own research motivation. We conducted a secondary analysis with empirical data from a research project involving physicians and patients in a clinical research setting of a biomarker study for rectal cancer treatment. Our empirical data included observations of physician–patient consultations and semi-structured interviews with patients. Overall, we collected 93 interviews. We found two dominant communication patterns, which physicians applied for motivating patients to take part in this research study. Some forms of these patterns tend to mislead patients’ understanding, while others could justifiably be applied in this consultation setting without undermining patients’ autonomy. This insight that the physician–patient communication has a strong influence on patients increases the importance to strengthen physicians’ ethically acceptable communication patterns regarding research participation. We further suggest that there is a need for a critical reflection of the ethics committee’s requirements for information regarding research participation. (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)

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)

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)

Relation between physicians and pharmaceutical industry is required for the benefit of the patient. But it may turn into business and overthrow the patients’ benefit. The relation might be in question at present and in future. Several questions are flowing in Bangladesh. To solve these queries we have explored the situation in developed and developing countries. The physicians and associations of pharmaceutical industries developed several ethical guidelines in those countries. They have addressed the long lasting issues on gift provided (...) to physician, cash back, sample, industry sponsored scientific meetings, research and hospitality. There are huge restrictions to ensure the right of the patient’s e.g. limitation of inexpensive gift by the pharmaceuticals, avoiding expensive medicine instead of equally effective low priced medicine. We are lacking behind to protect the patient right properly: regulation, adherence to existing guide line, lack of guidance from statutory bodies. The current scenario is far behind the right of patient. In Bangladesh it is not yet addressed either by professionals or by pharmaceutical associations. It is the immediate need to construct a guide line for physicians and pharmaceutical industry of Bangladesh.Bangladesh Journal of Bioethics 2015 Vol.6 (1):1-5. (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)

Are fake diagnoses and false or misleading certificates permissible means of helping patients? This question is examined in relation to four examples from Swedish health care: the sterilisation case, the asylum case, the virginity case, and the adoption case.We argue that both consequentialist and deontological ethical theories, to be reasonable, need to balance values, principles, and interests such as wellbeing, truthfulness, autonomy, personal integrity, trust in the medical profession, and abidance by national legislation.We conclude that it can be justifiable for (...) physicians to fake diagnoses and write false or misleading certificates in order to help patients when not doing so has dire consequences. However, physicians must also consider the long-term effects of making exceptions to honest, non-deceitful behaviour based on the best empirical evidence available. Otherwise valuable social practices might erode and public confidence in physicians be threatened. (shrink)

Wait, what? I've been fired?” I repeated, in the middle of morning rounds in the neonatal intensive care unit. Finally, the nurse who was taking care of our patient, Angela, responded, “Her parents fired you last night. They've already called Patient Relations. They want a new doctor.” My heart sank. Only days into my block of service time as the attending physician in the NICU and I was fired, axed, canned, rejected by a family. How could (...) this have happened? On my first day of service, I had introduced myself to Angela's parents, and I had then met with them daily to review results and the plan and to answer their questions. I thought we had connected well. I thought I had done everything right. I thought they trusted me to care for their daughter. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Ideal of Shared Decision Making Between Physicians and PatientsDan W. Brock (bio)IntroductionShared treatment decision making, with its division of labor between physician and patient, is a common ideal in medical ethics for the physician-patient relationship.1 Most simply put, the physician's role is to use his or her training, knowledge, and experience to provide the patient with facts about the diagnosis and about (...) the prognoses without treatment and with alternative treatments. The patient's role in this division of labor is to provide the values—his or her own conception of the good—with which to evaluate these alternatives, and to select the one that is best for himself or herself. As a rough guide to practice, this is a reasonable conception; most of the time it is likely to produce sound treatment decisions. However, as an ideal it is too simplistic, and is subject to several challenges that I will explore in this paper.Some challenges relate to the physician's role. This facts/values division of labor seems to assume that the physician can and should provide the facts about treatment alternatives in a value-neutral form. But some have questioned whether the sciences on which medicine is based are, or can be, value free. Moreover, the concepts of health and disease, and of the normal and pathological, are held by many to be value laden. And even if it is possible for physicians to provide only value-neutral facts to the patient, should the physicians' role be restricted in this way?Other challenges that I will present in the paper are to the patient's role [End Page 28] as provider of the values for the evaluation of the different treatment alternatives. One defense of this role is based on the claim that physicians are not in a position to know reliably what is in a patient's best interests (Buchanan, forthcoming). I believe at least as influential—even if often not explicitly stated—is an extreme subjectivism about values that assumes that the patient's own ultimate values, which define his or her own conception of the good, are incorrigible. By incorrigible, I mean they cannot be mistaken. In the standard case in which treatment is pursued for the patient's benefit, this extreme subjectivism is thought to support the patient's values guiding treatment decision making and treatment. I will explore this incorrigibility claim and will argue that on each of the main philosophical conceptions of the good for persons it is indefensible and should not be the basis for shared treatment decision making.Underlying this view of the physician-patient division of labor are assumptions and beliefs about the nature and relation of facts and values, and science and ethics, that are largely the legacy of a logical positivism that has long since been rejected by most philosophers. It is time that these unstable foundations for our normative ideal of the physician-patient relation were finally removed and replaced with more defensible underpinnings.Two Models of the Physician-Patient RelationshipPositivists insisted on a relatively sharp distinction between descriptive or empirical claims and science, on the one hand, and evaluative claims and ethics, on the other.2 Descriptive statements and the claims of science were to be true or false according to whether they in fact correctly described and explained the world. By remaining properly descriptive or empirical, science could, at least in principle, be entirely value neutral or value free.In its more extreme versions, positivism held that ethical judgments lacked cognitive content, but were instead expressions of emotions or attitudes, and as such could be neither true nor false, correct or mistaken. Because no evaluative statements were held to be logically entailed by any descriptive or empirical statements, moral reasoning was thought to be properly understood not as reasoning but as attempts at nonrational persuasion.3 Many drew from this an extreme subjectivism in ethics along the lines of what I have called above the incorrigibility thesis—there is no meaningful sense in which an individual's ultimate values defining his or her own conception of the good life could be mistaken, false, or unfounded.These... (shrink)

Some of the human relations of doctor and patient, by D.L. Edsall.--The care of patients. Its psychological aspects, by C.F. Martin.--The medical education of Jones, by Smith, by W.S. Thayer.--The significance of illness, by A.F. Riggs.--Some psychological observations by the surgeon, by F. G. Balch.--Human nature and its reaction to suffering, by L.K. Lunt.--The care of the aged, by A. Worcester.--The care of the dying, by A. Worcester.--Attention to personality in sex hygiene, by A. Worcester.

No profession has undergone as much scrutiny in the past several decades as that of medicine. Indeed, one might well argue that no profession has ever undergone so much change in so short a time. An essential part of this change has been the growing insistence that competent, adult patients have the right to decide about the course of their own medical treatment. However, the familiar and widely accepted principle of patient self-determination entails a corollary that has received little (...) attention in the growing literature on the ethics of physician-patient relations: if patients are to direct the course of their own medical treatment, then physicians are at least sometimes to be guided in their actions on behalf of patients by values that are not, and may even be incompatible with, their own values. Unless it is supposed that it would be best if physicians were simply to accommodate any and all patient requests, a possibility I consider and reject in this paper, there are bound to be numerous instances of legitimate moral conflict between the preferences of physicians and patients. In this paper, I examine the implications of this sort of moral conflict from the standpoint of the integrity of the physician. -/- Critical to a proper appreciation of the significance of this conflict is a distinction that the literature on biomedical ethics has largely failed to draw: that between medical paternalism and physician integrity. (shrink)

Scientific authority and physician authority are both challenged by Thomas Kuhn's concept of incommensurability. If competing “paradigms” or “world views” cannot rationally be compared, we have no means to judge the truth of any particular view. However, the notion of local or partial incommensurability might provide a framework for understanding the implications of contemporary philosophy of science for medicine. We distinguish four steps in the process of translating medical science into clinical decisions: the doing of the science, the appropriation (...) of the scientific findings by the clinician, the transfer of the findings from the clinician to the patient, and the choice of a treatment regimen. Incommensurability can play a role in each stage. There is at least some theory- and value-ladenness in science that is dependent on the world view of those who construct the scientific theories. Clinicians who must use the results of scientific research will inevitably interpret the research from the standpoint of their own world view. There may be further incommensurability when these data are communicated to the patient. Finally, clinician and patient values must come into play in any decision about choice of treatment. No stage of medical research or practice is value-free. This position does not imply relativism; some scientific accounts are better than others. However, the challenge of the incommensurabilists shows that further analysis is needed to establish how particular accounts are better or worse. (shrink)

Considered ahead of its time since the first publication in 1981, Medical Choices, Medical Chances provides a telescope for viewing how developments in the fields of medical research, medical technology, and health care organization are likely to influence the doctor-patient relationship in the 21st Century. The book explores this intricate web of relationships among doctors, patients, and families and offers a new framework for mastering the emotional and intellectual challenges of uncertainty, while at the same time providing tools for (...) all concerned to regain control from managed care. It is a must-read for all those interested in medicine and where it is headed in the new millennium. (shrink)

Perez-Rodriguez and de la Fuente (2017) assume that although human races do not exist in a biological sense (“geneticists and evolutionary biologists generally agree that the division of humans into races/subspecies has no defensible scientific basis,” they exist only as “sociocultural constructions” and because of that maintain an illusory reality, for example, through “racialized” practices in medicine. Agreeing with the main postulates formulated in the article, we believe that the authors treat this problem in a superficial manner and have failed (...) to capture the current state of the field of knowledge in science and the humanities. In our commentary, we want to highlight two main omissions, and to notice three important implications for “a postracial medicine.”. (shrink)

As the median age of practicing physicians increases, ethical dilemmas due to age-related cognitive decline among clinicians will become ever more pressing. Compelling data show that despite acknowledgement of their duty to protect the public, physicians often fail to report themselves, their colleagues, or their physician-patients when cognitive decline appears to impact medical practice adversely. As such, efforts to educate physicians about ethical obligations and various tactful methodologies to report themselves or others seem ineffective. Illustrated by a case report (...) of age-related cognitive decline in a practicing physician, practical recommendations are made both to develop and validate cognitive screening in middle-aged physicians, presumably before the onset of age-related cognitive decline. (shrink)

ObjectiveIn Belgium, people with an incurable psychiatric disorder can file a request for euthanasia claiming unbearable psychic suffering. For the request to be accepted, it has to meet stringent legal criteria. One of the requirements is that the patient possesses decision-making capacity. The patient’s decision-making capacity is assessed by physicians.The objective of our study is to provide insight in the assessment of decision-making capacity in the context of euthanasia for patients with psychic suffering caused by a psychiatric disorder.MethodTwenty-two (...) semistructured interviews with psychiatrists and neurologists were analysed with NVivo, a qualitative analysis software to code and organise transcribed data.ResultsDifferent views and approaches regarding decision-making capacity in the context of euthanasia emerged from the data.Most of the physicians have some knowledge of the cognitive ability approach on decision-making capacity. According to this approach, four abilities constitute decision-making capacity: communication, understanding, appreciation and reasoning. We observed differences in the way these abilities are valued in relation to competence. Some physicians take additional elements into consideration when assessing decision-making capacity.Physicians acquired their knowledge on the subject in many different ways. Most of the physicians reported that decision-making capacity was not part of their training.ConclusionWe conclude that physicians assess decision-making capacity in different ways and that personal values and beliefs influence their approach. As such, a common approach in assessing the decision-making capacity of a patient among the interviewed physicians is lacking. Less arbitrariness could be obtained by consistently implementing the cognitive ability approach. (shrink)

Charles Taylor's retrieval of an expressivist understanding of persons, and of language as constitutive of meaning, contains promising insights for restoring moral connectedness between patients and physicians.

A questionnaire relating to attitudes towards setting economic priorities within the health care system was sent to all 151 general practitioners in Northern Norway. Of these, 109 (72 per cent) responded. Ninety-six per cent of the respondents agreed or partly agreed that the setting of economic priorities within the health care system was necessary. Ninety-three per cent had experienced a conflict between their responsibility towards the individual patient and the requirement for them to manage the health budget. The responses (...) suggest that doctors act more in the interests of their patient than the interests of society. However, 68 per cent reported having refrained from giving the best treatment to patients because it was too expensive. As many as 60 per cent of the respondents wanted more public guidelines. Only 10 per cent wanted doctors to have more influence in difficult questions arising from setting priorities. (shrink)

Physician-assisted death (PAD) of patients whose suffering does not stem from terminal conditions has become more prevalent during the last few decades. This paper is focused on decision-making competence for PAD, specifically in situations in which PAD is related solely to psychiatric illness. First, a theoretical analysis presents the premises for the argument that competence for physician-assisted death for psychiatric patients (PADPP) should be determined based on a higher threshold in comparison to the required competence for conventional medical (...) interventions. Second, the higher threshold for decision-making competence for PADPP is illustrated. Third, several real PADPP cases are critically discussed, as an illustration to decision-making competence evaluations that would not have met the higher standard. Finally, a short summary of practical suggestions regarding the assessment of decision-making competence for PADPP is presented. Psychiatrists are called to address the ethical, legal, societal and clinical challenges related to PADPP and should be prepared for its probable expansion. (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 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)

This paper examines the case for an expanded interpretation of the concept of “material risk” such that it necessitates voluntary disclosure of physician inexperience with a specific medical procedure. Informed consent law in the United States, Canada, and most commonwealth jurisdictions has become a driver of standards of risk disclosure by physicians during the informed consent process. The legal standard of risk disclosure expected of a physician hinges on the interpretation of the entity called “material risk.” Any impairment (...) of the physician related to drug usage, disease, or alcohol which compounds the risk of a procedure is very likely to be considered material by a patient. This paper argues that physician inexperience is a factor that a reasonable patient would attach significance to and that it should therefore be viewed as a “material risk” requiring disclosure. (shrink)

New brain-computer interface and neuroimaging techniques are making differentiation less ambiguous and more accurate between unresponsive wakefulness syndrome patients and patients with higher cognitive function and awareness. As research into these areas continues to progress, new ethical issues will face physicians of patients suffering from total locked-in syndrome, characterized by complete loss of voluntary muscle control, with retention of cognitive function and awareness detectable only with neuroimaging and brain-computer interfaces. Physicians, researchers, ethicists and hospital ethics committees should be aware of (...) and prepared to handle ethical issues unique to these totally locked-in patients. Several thought experiments are discussed, to highlight potential ethical dilemmas surrounding surrogate decision-making, autonomy, end-of-life care, and pediatric care, which will be unique to total LIS patients. These, along with other ethical problems especially relevant to total LIS patients, merit further discussion among physicians, researchers, ethicists and hospital ethics committees, to facilitate consensus regarding these issues, and improve patient care. (shrink)

Euthanasia and physician-assisted suicide (PAS) by request and/or based on an advance directive are legal in The Netherlands under strict conditions, thus providing options for patients with Huntington's disease (HD) and other neurodegenerative diseases to stay in control and choose their end of life. HD is an inherited progressive disease characterised by chorea and hypokinesia, psychiatric symptoms and dementia. From a qualitative study based on interviews with 15 physicians experienced in treating HD, several ethical issues emerged. Consideration of these (...) aspects leads to a discussion about the professional role of a physician in relation to the personal autonomy of a patient. Such a discussion can raise awareness that talking about end-of-life wishes with an HD patient is part of the legal, professional and moral responsibility of the physician, and that a letter of intent on behalf of the physician can improve active participation in the process. Discussion of these issues can help to advance the debate on euthanasia and PAS in HD and other neurodegenerative diseases. (shrink)

This paper evaluates the arguments against physician assisted suicide which contend that it violates the integrity of medicine and the physician-patient relation; i.e. that it contradicts the goal of seeking health and healing, violates an absolute prohibition against killing, and undermines the patient's trust in the physician. These arguments against physician assisted suicide (1) misuse notions of teleology and teleological explanation; (2) rely on inappropriate notions of "ideal medicine", for which death is a defeat; (...) (3) turn on a highly selective reading for the Hippocratic tradition; and (4) are unacceptably paternalistic. Keywords: Hippocratic ethics, integrity in medicine, physician assisted suicide, physician-patient relation CiteULike Connotea Del.icio.us What's this? (shrink)

This book is a collection of papers presented at an interdisciplinary workshop at the Calgary Institute for the Humanities in May 1980. The three broad issues covered are: the physician-patient relationship, the allocation of responsibility among doctors and nurses, and the political and social framework of the health care system. The first set of essays is concerned with the moral and legal aspects of the physician-patient relationship. The link between knowledge and power is examined as well (...) as the moral dilemmas posed by medical technology. These initial essays would alone justify this publ. (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)

In todays’ super-diverse societies, communication and interaction in clinical encounters are increasingly shaped by linguistic, cultural, social and ethnic complexities. It is crucial to better understand the difficulties patients with migration background and healthcare professionals experience in their shared clinical encounters and to explore ethical aspects involved. We accompanied 32 migrant patients during their medical encounters at two outpatient clinics using an ethnographic approach. Overall, data of 34 interviews with patients and physicians on how they perceived their encounter and which (...) difficulties they experienced are presented. We contrasted the perspectives on the difficult aspects and explore ethical questions surrounding the involved issues. Patients and physicians describe similar problem areas, but they have diverging perspectives on them. Two main themes were identified by both patients and physicians: >patients’ behaviour in relation to doctors’ advice relationship issues<. A deeper understanding of the difficulties and challenges that can arise in cross-cultural settings could be provided by bringing together healthcare professionals’ and patients’ perspectives on how a cross- cultural clinical encounter is perceived. Ethical aspects surrounding some of the difficulties could be highlighted and should get more attention in clinical practice and research. (shrink)

The objective of this article is to establish an alternative doctor-patient relationship model and describe its importance in the case of the doctor-patient relationship in Bangladesh. There is a lot of diversity in the religious beliefs, social norms and values in Bangladesh. Likewise, the development of biological science as well as medical technology, the allocation of healthcare resources must be considered as an important issue. That is why the autonomy of both doctor and patient is a relational (...) factor here. Besides, the four traditional doctor-patient relationship models offered by Ezekiel J. Emanuel and Linda L. Emanuel are not beyond criticism. So, we need an ideal doctor-patient relationship model for Bangladesh to protect every patient’s autonomy which will give freedom to the patient in choosing their own treatment as well as which will not conflict with the patient’s social or cultural values. In this article, I have selected the relational model of autonomy as the method of alternative doctor-patient relationship model. Hopefully, this alternative model will work better since it considers care first concerning a patient’s autonomy. Besides, doctors would treat their patients as a ‘care seeker’ rather than ‘client’ or ‘customer’, and simultaneously, patients would perceive their physicians as ‘caregivers’. But, applying the relational model of autonomy in the case of doctor-patient relationship is more challenging in Bangladesh due to some obstacles like large numbers of population, illiteracy, insufficiency of skilled doctors and hospitals, corruption in medical sectors, social prejudices and so on. But, if we can overcome these problems, the relational model of autonomy will be considered as a suitable doctor-patient relationship model in Bangladesh. (shrink)

While twentieth-century medical ethics has focused on the duty of physicians to benefit their patients, the next century will see that duty challenged in three ways. First, we will increasingly recognize that it is unrealistic to expect physicians to be able to determine what will benefit their patients. Either they limit their attention to medical well-being when total well-being is the proper end of the patient or they strive for total well-being, which takes them beyond their expertise. Even within (...) the medical sphere, they have no basis for choosing among the proper medical goals for medicine. Also, there are many plausible strategies for relating predicted benefits to harms, and physicians cannot be expert in picking among these strategies. Second, increasingly plausible ethical systems recognize that in some cases, patient benefit must be sacrificed to protect patient rights including the right to the truth, to have promises kept, to have autonomy respected, and to not be killed. Third, ethics of the next century will increasingly recognize that some patient benefits must be sacrificed to fulfill duties to others - either the duty to serve the interests of others or other duties such as keeping promises, telling the truth, and, particularly, promoting justice. Physicians in the twenty-first century will be seen as having a new, more limited duty to assist the patient in pursuing the patient's understanding of the patient's interest within the constraints of deontological ethical principles and externally imposed duties to promote justice. The result will be a duty to be loyal to the consumer of health care with the recognition that often this will mean that the physician is not permitted to pursue the physician's understanding of the patient's well-being. (shrink)