Professionalism requires that physicians uphold the best interests of patients while simultaneously insuring just use of health care resources. Current articulations of these obligations like the American Board of Internal Medicine Foundation's Physician Charter do not reconcile how these obligations fit together when they conflict. This is the problem of dual agency. The most common ways of dealing with dual agency: “bunkering”—physicians act as though societal cost issues are not their problem; “bailing”—physicians assume that they are merely agents of society (...) and deliver care typically based on a strongly consequentialist public health ethic; or “balancing”—a vaguely specified attempt to uphold both patient welfare and societal need for judicious resource use simultaneously—all fail. Here I propose how the problem of dual agency might begin to be addressed with rigor and consistency. Without dealing with the dual agency problem and getting more specific about how to reconcile its norms when they conflict, the expectations of professionalism risk being written off as cute, nonbinding aphorisms from the medical profession. (shrink)

Principlism is simple. Four intuitive ideas, creating order out of moral chaos, at least categorizing considerations for better deliberation over right and wrong, good and bad, in a modern, plurali...

Important discussions about limiting care based on professional judgment often devolve into heated debates over the place of physicians in bedside rationing. Politics, loaded rhetoric, and ideological caricature from both sides of the rationing debate obscure precise points of disagreement and consensus, and hinder critical dialogue around the obligations and boundaries of professional practice. We propose a way forward by reframing the rationing conversation, distinguishing between the scale of the decision and its context avoiding the word “rationing.” We propose to (...) shift the terminology, using specific, descriptive words to defuse conflict and re-focus the debate towards substantive issues. These distinctions can clarify the real ethical differences at stake and facilitate a more constructive conversation about the clinical and social responsibilities of physicians to use resources ethically at the bedside and their role in allocating medical resources at a societal level. (shrink)

Important discussions about limiting care based on professional judgment often devolve into heated debates over the place of physicians in bedside rationing. Politics, loaded rhetoric, and ideological caricature from both sides of the rationing debate obscure precise points of disagreement and consensus, and hinder critical dialogue around the obligations and boundaries of professional practice. We propose a way forward by reframing the rationing conversation, distinguishing between the scale of the decision and its context avoiding the word “rationing.” We propose to (...) shift the terminology, using specific, descriptive words to defuse conflict and re-focus the debate towards substantive issues. These distinctions can clarify the real ethical differences at stake and facilitate a more constructive conversation about the clinical and social responsibilities of physicians to use resources ethically at the bedside and their role in allocating medical resources at a societal level. (shrink)

Volume 20, Issue 4, May 2020, Page 76-78.

We reflect on Dr. Iserson’s article in this journal, in which he suggests that clinicians must “shove” patients towards appropriate care. While recognizing that overt clinical guidance is part of care, we suggest that its use should be tempered by the guidance’s responsiveness to the human and emotional experience of each patient.

We agree with Lynch et al. that patients with chronic diseases and Band-Aid treatments are unlikely to benefit from a version of Operation Warp Speed or by deprioritizing standards of scientific ev...

Obtaining informed consent is a cornerstone of biomedical research, yet participants comprehension of presented information is often low. The most effective interventions to improve understanding rates have not been identified.

Moral pluralism is the norm in contemporary society. Even the best philosophical arguments rarely persuade moral opponents who differ at a foundational level. This has been vividly illustrated in contemporary debates in bioethics surrounding contentious issues such as abortion and euthanasia. It is readily apparent that bioethics discourse lacks an empirical explanation for the broad differences about various topics in bioethics and health policy. In recent years, social and cognitive psychology has generated novel approaches for defining basic differences in moral (...) intuitions generally. We propose that if empirical research using social intuitionist theory explains why people disagree with one another over moral issues, then the results of such research might help people debate their moral differences in a more constructive and civil manner. We illustrate the utility of social intuitionism with data from a national physician survey. (shrink)

Physicians vary in their moral judgments about health care costs. Social intuitionism posits that moral judgments arise from gut instincts, called “moral foundations.” The objective of this study was to determine if “harm” and “fairness” intuitions can explain physicians’ judgments about cost-containment in U.S. health care and using cost-effectiveness data in practice, as well as the relative importance of those intuitions compared to “purity”, “authority” and “ingroup” in cost-related judgments.

Purpose: to characterize ethics course content, structure, resources, pedagogic methods, and opinions among academic administrators and course directors at U.S. medical schools. Method: An online questionnaire addressed to academic deans and ethics course directors identified by medical school websites was emailed to 157 Association of American Medical Colleges member medical schools in two successive waves in early 2022. Descriptive statistics were utilized to summarize responses. Results: Representatives from 61 (39%) schools responded. Thirty-two (52%) respondents were course directors; 26 (43%) were (...) deans of academic affairs, medical education, or curriculum; and 3 with other roles also completed the survey (5%). All 61 schools reported some form of formal ethics education during the first year of medical school, with most (n = 54, 89%) reporting a formal mandatory introductory course during preclinical education. Schools primarily utilized lecture and small-group teaching methods. Knowledge-based examinations, attendance, and participation were most commonly used for assessment. A large majority regarded ethics as equally or more important than other foundational courses, but fewer (n = 37, 60%) provided faculty training for teaching ethics. Conclusions: Despite a response rate of 39 percent, the authors conclude that medical schools include ethics in their curricula in small-group and lecture formats with heterogeneity regarding content taught. Preclinical curricular redesigns must innovate and implement best practices for ensuring sound delivery of ethics content in future curricula. Additional large-scale research is necessary to determine said best practices. (shrink)

Revisionists and traditionalists appeal to Acts 15, welcoming the Gentiles, for analogies directing the church's response to homosexual persons. John Perry has analyzed the major positions. He faults revisionists for inadequate attention to the Jerusalem Decree and faults one traditionalist for using the Decree literally rather than through analogy. I argue that analogical use of the Decree must supplement rather than displace the plain sense. The Decree has been neglected due to assumptions that Paul opposed it, that it expired, or (...) because Gentiles wanted non-kosher meat. I argue that Paul continued to observe the Torah and supported the Decree, that it has not expired, and that Gentile desire for non-kosher meat is not a firm obstacle. Affirming the plain sense of the Decree, I develop the analogy from Acts 15 to homosexual persons. (shrink)

Traditional approaches to character education have been viewed by many educators as an attempt to establish self control within students to habituate them to prescribed behaviour and as nothing more than a ‘bits‐and‐pieces’ approach to moral education. While this is accurate for many character education programmes, integrated multi‐dimensional character education embraces both moral education and character formation. Students learn to identify and process social conventions within the core values of the school and community and have opportunities to learn practical reasoning (...) skills in schools where character education is integrated into all aspects of the schooling process. Reported in this article are several studies, including two large‐scale experimental investigations, that show integrated character education results in an improved school environment, student pro‐social and moral behaviour, and reading and maths test scores. Schools become more caring communities; student discipline referrals drop significantly, particularly in areas related to bullying behaviour; and test scores in moderately achieving schools increase nearly 50%. (shrink)

Revisionists and traditionalists appeal to Acts 15, welcoming the Gentiles, for analogies directing the church's response to homosexual persons. John Perry has analyzed the major positions. He faults revisionists for inadequate attention to the Jerusalem Decree and faults one traditionalist for using the Decree literally rather than through analogy. I argue that analogical use of the Decree must supplement rather than displace the plain sense. The Decree has been neglected due to assumptions that Paul opposed it, that it expired, or (...) because Gentiles wanted non-kosher meat. I argue that Paul continued to observe the Torah and supported the Decree, that it has not expired, and that Gentile desire for non-kosher meat is not a firm obstacle. Affirming the plain sense of the Decree, I develop the analogy from Acts 15 to homosexual persons. One strand of the church's conversation about homosexuality compares present-day acceptance of homosexuals to the church's acceptance of Gentiles in Acts 15. In a previous article, "Gentiles and Homosexuals," I presented the history of that strand. In a reply to my article, Olson proposes to reimagine the analogy via the "radical new perspective on Paul" and argues that doing so exposes problems with my original analysis. I defend myself against these criticisms, while also entering into the spirit of Olson's reimagined analogy. Expanding the scope beyond Acts to Paul opens up important facets that might otherwise be obscured. In particular, it includes voices that are sometimes silenced, and presses both sides for an account of sexuality grounded in vocation and God's purposes in creation. (shrink)

In 2007 th eAustralian government declared that remote Aboriginal communities were in crisis and launched the Northern Territory Intervention.

Disruptions in dopamine transmission within the basal ganglia (BG) produce deficits in voluntary actions, that is, in the interface between cortically-generated goal representation and BG-mediated response selection. Under conditions of dopamine loss in humans and other animals, responses are impaired when they require internal generation, but are relatively intact when elicited by external stimuli.

It was the spring of 2020 when the email came to our inboxes—a memo from our Institutional Review Board informing us that we were approved to begin conducting our pragmatic clinical trial with a wa...

A traditional ethic of medicine asserts that physicians have special obligations to individual patients with whom they have a clinical relationship. Contemporary trends in US healthcare financing like bundled payments seem to threaten traditional conceptions of special obligations of individual physicians to individual patients because their population-based focus sets a tone that seems to emphasise responsibilities for groups of patients by groups of physicians in an organisation. Prior to undertaking a cogent debate about the fate and normative weight of special (...) obligations and a traditional ethic for contemporary healthcare, we need a deeper examination of what the traditional ethic of special obligations really means. Here we offer a conception of ‘doubly distributed’ special obligations. Physicians and similarly minded healing professionals abiding by a traditional ethic have always spread their devotion and attention across multiple patients and have shared responsibilities with physician and non-physician colleagues in much the same way devoted parents have frequently distributed their special obligations across multiple children and across multiple parents. By taking up the extended analogy of parent we argue that doubly distributing special obligations need not contradict the possibility of special obligations in restructured collective forms of healthcare delivery and financing. (shrink)

A traditional ethic of medicine asserts that physicians have special obligations to individual patients with whom they have a clinical relationship. Contemporary trends in US healthcare financing like bundled payments seem to threaten traditional conceptions of special obligations of individual physicians to individual patients because their population-based focus sets a tone that seems to emphasise responsibilities for groups of patients by groups of physicians in an organisation. Prior to undertaking a cogent debate about the fate and normative weight of special (...) obligations and a traditional ethic for contemporary healthcare, we need a deeper examination of what the traditional ethic of special obligations really means. Here we offer a conception of ‘doubly distributed’ special obligations. Physicians and similarly minded healing professionals abiding by a traditional ethic have always spread their devotion and attention across multiple patients and have shared responsibilities with physician and non-physician colleagues in much the same way devoted parents have frequently distributed their special obligations across multiple children and across multiple parents. By taking up the extended analogy of parent we argue that doubly distributing special obligations need not contradict the possibility of special obligations in restructured collective forms of healthcare delivery and financing. (shrink)

Previous research (Kielbasa, Pomerantz, Krohn, & Sullivan, 2004; Pomerantz & Segrist, 2006) indicates that when psychologists consider a client with symptoms of depression or anxiety, payment method significantly influences diagnostic decisions. This study extends the scope of the previous research to consider clients with symptoms of social phobia and attention deficit hyperactivity disorder (ADHD). Psychologists in independent practice responded to vignettes of clients whose descriptions deliberately included subclinical impairment. Half of the participants were told that the clients would pay via (...) managed care; the other half were told that the clients would pay out-of-pocket. Confirming previous studies, payment method had a highly significant impact on diagnosis such that compared to out-of-pocket clients, managed care clients were much more likely to be assigned Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994) diagnoses. Ethical implications relate to informed consent, accuracy and truthfulness in diagnosis, and psychologists' integrity. (shrink)

How does one committed to the claims of Christ and a biblical story of redemption live Christianly and navigate the competing worldviews encountered in everyday medical practice? Adopting the practical conceptual framework promoted by Reformed Christian philosopher and theologian Albert Wolters, we argue for an all-encompassing biblical understanding of God’s cosmic redemption plan for the entire creation order in contrast to a more typical sacred/secular duality. We then apply the concepts of structure and direction, drawn from a pretheological understanding of (...) human life drawn from the Scripture, to a semi-fictional case study in discerning Christian faithfulness in everyday mundane aspects of medicine. Our subsequent analysis seeks to render an interpretation of what it means to live life consistent with that worldview when confronted with challenges like those presented in the case. (shrink)

Teaching ethics is crucial to health sciences education. Doing it well requires a willingness to engage contentious social issues. Those issues introduce conflict and risk, but avoiding them ignores moral diversity and renders the work of ethics education irrelevant. Therefore, when (not if) contentious issues and moral differences arise, they must be acknowledged and can be addressed with humility, collegiality, and openness to support learning. Faculty must risk moments when not everyone will “feel safe,” so the candor implied in psychological (...) safety can emerge. The deliberative and social work of ethics education involves generous listening, wading into difference, and wondering together if our beliefs and arguments are as sound as we once thought. By forecasting the need for candid engagement with contentious issues and moral difference, establishing ground rules, and bolstering due process structures for faculty and students, a riskier and more relevant ethics pedagogy can emerge. Doing so will prepare everyone for the moral diversity they can expect in our common life and in practice. (shrink)

In the detailed, cogent, and well‐referenced Rationing Is Not a Four‐Letter Word: Setting Limits on Healthcare, Phillip Rosoff takes up an emotion‐laden entrenched argument as challenging as iPhone purchasing for teens—trying to convince a skeptical public and medical profession that “rationing” is just fine. According to Rosoff, despite its near expletive status, the “R word”—the much‐maligned third rail of American health policy‐is an inevitable and sensible choice for the future of health care in the United States. It is—rather like the (...) iPhone 4S—good enough, much cheaper, and really not that bad. (shrink)

Volume 20, Issue 9, September 2020, Page 26-28.

This volume introduces the major classical Arabic philosophers through substantial selections from the key works (many of which appear in translation for the first time here) in each of the fields—including logic, philosophy of science, natural philosophy, metaphysics, ethics, and politics—to which they made significant contributions. -/- An extensive Introduction situating the works within their historical, cultural, and philosophical contexts offers support to students approaching the subject for the first time, as well as to instructors with little or no formal (...) training in Arabic thought. A glossary, select bibliography, and index are also included. (shrink)

This article uses concepts from sociology, history, and philosophy to explore the shifting relationship between moral values and business in the Western world. We examine the historical roots and intellectual underpinnings of two major business-society paradigms in ideal-type terms. In pre-industrial Western society, we argue that business activity was linked to society’s values of morality (the moral unity paradigm}-for good or for ill. With the rise of industrialism, we contend that business was freed from moral constraints by the alleged “invisible (...) hand” of efficient markets (the amoral theory of business). Armed with this understanding of the intellectual history of the moral unity and amoral business-society paradigms, we suggest that some variant of the moral unity paradigm may be recurring in post-industrial society. (shrink)

This article uses concepts from sociology, history, and philosophy to explore the shifting relationship between moral values and business in the Western world. We examine the historical roots and intellectual underpinnings of two major business-society paradigms in ideal-type terms. In pre-industrial Western society, we argue that business activity was linked to society’s values of morality (the moral unity paradigm}-for good or for ill. With the rise of industrialism, we contend that business was freed from moral constraints by the alleged “invisible (...) hand” of efficient markets (the amoral theory of business). Armed with this understanding of the intellectual history of the moral unity and amoral business-society paradigms, we suggest that some variant of the moral unity paradigm may be recurring in post-industrial society. (shrink)

Many in academic bioethics worry that robust theological traditions, when articulated in the public square, damage the prospect of serious reflection about tough cases. Here we challenge that prevailing exclusion-by-default methodological impulse by correcting prevalent stereotypes about one particular Christian tradition that may offer relevant conceptual resources for bioethics. We briefly examine the man, John Calvin, and the Calvinist/Reformed Protestant tradition to show how it has been misconstrued in academic bioethics but can be reconstrued as a constructive, substantive theological starting (...) point for tough bioethical questions of our age. Core Calvinist doctrines about the nature of an all-sovereign God and human beings’ relation to that God, as well as related prominent themes from elements of the broader Reformed tradition, including the glory/sovereignty/majesty of God; the created goodness of the world; human beings as desiring/worshiping/image-bearing creatures; the pervasive influence of sin; the limitations of humanity for self-improvement; the completely gratuitous nature of redemption; the comprehensiveness of God’s redemptive purposes; and the pending final completion of his redemptive work could and should influence the tone and content of moral deliberation that can be a positive influence on twenty-first-century bioethics. (shrink)

We evaluate here the performance of four models of cross-situational word learning: two global models, which extract and retain multiple referential alternatives from each word occurrence; and two local models, which extract just a single referent from each occurrence. One of these local models, dubbed Pursuit, uses an associative learning mechanism to estimate word-referent probability but pursues and tests the best referent-meaning at any given time. Pursuit is found to perform as well as global models under many conditions extracted from (...) naturalistic corpora of parent-child interactions, even though the model maintains far less information than global models. Moreover, Pursuit is found to best capture human experimental findings from several relevant cross-situational word-learning experiments, including those of Yu and Smith (), the paradigm example of a finding believed to support fully global cross-situational models. Implications and limitations of these results are discussed, most notably that the model characterizes only the earliest stages of word learning, when reliance on the co-occurring referent world is at its greatest. (shrink)

Smythe and Murray presented the basic ethical issues in narrative research in a comprehensive, well-reasoned, and direct manner. In this critique, we highlight 3 issues. Two matters appear to challenge the internal inconsistency of the assumptions of NR: privileging some voices over others and a potential inherent conflict of interest for some researchers. We also examine some issues regarding the protection of research participants and conclude with modest recommendations.