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Virtue Ethics and Public Policy: Upholding Medical Virtue in Therapeutic Relationships as a Case Study

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Notes

  1. I wish to thank Richard Hamilton for his guidance, and Kyle A. McGregor and other participants in the 2014 Yale University Summer Institute in Bioethics, along with an anonymous reviewer, for their helpful comments on an earlier draft of this paper. Part of the research for this paper was supported by Australian Research Council Discovery Project research grant DP1094577.

  2. See e.g. Edmund Pellegrino and David Thomasma, The virtues in medical practice, New York, Oxford University Press, 1993; Jennifer Radden and John Z. Sadler, The Virtuous Psychiatrist: Character ethics in psychiatric practice, New York, Oxford University Press, 2010; Ros McDougall, ‘Parental virtue: a new way of thinking about the morality of reproductive actions’, Bioethics 21, no. 4, 2007, pp. 181–90; and Justin Oakley and Dean Cocking, Virtue Ethics and Professional Roles, Cambridge, Cambridge University Press, 2001.

  3. See Oakley and Cocking, op. cit., chapter 3; and Leon Kass, ‘Neither for Love nor Money: Why Doctors must not Kill’, The Public Interest 94, Winter 1989, pp. 25–6.

  4. See Oakley and Cocking, op. cit.; and Dean Cocking and Justin Oakley, ‘Indirect Consequentialism, Friendship, and the Problem of Alienation’, Ethics 106, no. 1, October 1995.

  5. See https://ama.com.au/position-statement/ama-code-ethics-2004-editorially-revised-2006.

  6. I do not mean to imply here that this commitment is necessarily made explicitly by all doctors; rather this commitment is sometimes an implicit one.

  7. By ‘clinically inappropriate prescribing’ I am referring to prescribing a medication which there is good reason to believe is not in the best health interests of the patient, compared with other available medication(s).

  8. See Paul Biegler and Patrick Vargas, ‘Ban the sunset? Nonpropositional content and regulation of pharmaceutical advertising’, American Journal of Bioethics 13, no. 5, May 2013, pp. 3–13; Paul Biegler, Jeanette Kennett, Justin Oakley, and Patrick Vargas, ‘Implicit persuasion and the ethics of pharmaceutical advertising’, in Jens Clausen and Neil Levy (eds.) Handbook of Neuroethics, Dordrecht, Springer, 2015.

  9. Elizabeth Murray, Bernard Lo, Lance Pollack, Karen Donelan, and Ken Lee, ‘Direct-to consumer advertising: Physicians’ views of its effects on quality of care and the doctor-patient relationship’, Journal of the American Board of Family Medicine 16, no. 6, 1 November 2003, pp. 513–524, p. 521. See also Elizabeth Murray, Bernard Lo, Lance Pollack, Karen Donelan, and Ken Lee, ‘Direct-to consumer advertising: Public perceptions of its effects on health behaviors, health care, and the doctor-patient relationship’, Journal of the American Board of Family Medicine 17, no. 1, Jan-Feb 2004, pp. 6–18; Barbara Mintzes et al., ‘Influence of direct to consumer pharmaceutical advertising and patients’ requests on prescribing decisions: two site cross sectional survey’, British Medical Journal 324, 2 February 2002, pp. 278–279; Barbara Mintzes et al., ‘How does direct-to-consumer advertising (DTCA) affect prescribing? A survey in primary care environments with and without legal DTCA’, Canadian Medical Association Journal 169, no. 5, 2 September 2003, pp. 405–412; and Richard L. Kravitz et al., ‘Influence of patients’ requests for direct-to-consumer advertised anti-depressants: A randomized controlled trial’, Journal of the American Medical Association 293, no. 16, 27 April 2005, pp. 1995–2002.

  10. S Gilbody, P Wilson, I Watt, ‘Benefits and harms of direct-to-consumer advertising: A systematic review’, Quality and Safety in Health Care 14, 2005, pp. 246-50, p. 246. The intractability of certain brand-specific preferences and requests due to the implicit persuasion techniques often used in such advertising is also likely to lead to increased levels of physician acquiescence to such requests (see Biegler et al., op. cit., 2015).

  11. Barbara Mintzes, ‘Advertising of Prescription-Only Medicines to the Public: Does Evidence of Benefit Counterbalance Harm?’ Annual Review of Public Health 2012, 33, pp. 259–277, p. 271. See also John B. McKinlay et al., ‘Effect of patient medication requests on physician prescribing behavior: Results of a factorial experiment’, Medical Care 52, no. 4, April 2014, pp. 294–299.

  12. See See J.S Weissman, et al. ‘Physicians Report on Patient Encounters Involving Direct-to-Consumer Advertising’, Health Affairs (Millwood). 2004 (suppl web exclusives): W4-219 – W4-233, p. W4-227. For a fascinating study of doctors’ explanations of their acting against their better judgement in making these clinically inappropriate prescribing decisions, see A. Tentler et al. ‘Factors Affecting Physicians’ Responses to Patients’ Requests for Antidepressants: Focus Group Study’, Journal of General and Internal Medicine 2008; 23, pp. 51–57.

  13. A more detailed analysis would also address the extent to which a doctor complying with DTCA patient requests redefines the relationship. Presumably this comes in degrees, just as we might say of a friendship – for example, a relationship is less of a friendship when someone is a fair-weather friend, but perhaps it takes further governing conditions to alter for the relationship to cease being a friendship altogether.

  14. See Tentler et al., op. cit. p. 53. I am grateful to an anonymous reviewer for raising this point.

  15. See Ibid, p. 53.

  16. Ashley Wazana, ‘Physicians and the pharmaceutical industry: Is a gift ever just a gift?’ Journal of the American Medical Association 283, 2000, pp. 373–380. See also Troyen A. Brennan, David J. Rothman, Linda Blank, David Blumenthal, Susan C. Chimonas, Jordan J. Cohen, Janlori Goldman, Jerome P. Kassirer, Harry Kimball, James Naughton, Neil Smelser, ‘Health industry practices that create conflicts of interest’, Journal of the American Medical Association 295, 2006, pp. 429–433, p. 431.

  17. M.A. Morgan, ‘Interactions of doctors with the pharmaceutical industry’, Journal of Medical Ethics 32, 2006, pp. 559–563.

  18. David Blumenthal, ‘Doctors and drug companies’, New England Journal of Medicine 351, 2004, pp. 1885–1890, p. 1886.

  19. See Leonard J. Weber, Profits before people? Ethical standards and the marketing of prescription drugs, Bloomington, Indiana University Press, 2006; and Marc A.Rodwin, Conflicts of interest and the future of medicine: The United States, France, and Japan, New York, Oxford University Press, 2011.

  20. See http://www.cms.gov/openpayments/.

  21. See eg. Rodwin, op. cit. pp. 215–219; and Genevieve Pham-Kanter, G. Caleb Alexander, and Kavita Nair, ‘Effect of physician payment sunshine laws on prescribing’, Archives of Internal Medicine 172, 2012, pp. 819–821.

  22. See Rodwin op. cit, pp. 16–20; Stephen Campbell, David Reeves, Evangelos Kontopantelis, Elizabeth Middleton, Bonnie Sibbald, and Martin Roland, ‘Quality of primary care in England with the introduction of pay for performance’, New England Journal of Medicine 357, 2007, pp. 181–190.

  23. See eg. Robert E. Goodin, Utilitarianism as a Public Philosophy, Cambridge, Cambridge University Press, 1995.

  24. See Campbell et al. op. cit.

  25. See Justin Oakley, ‘Sketch of a virtue ethics regulatory model: Response to commentaries’ (response to Tom Beauchamp, Alastair Campbell, Masatoshi Nara, and Ilhak Lee), in Akira Akabayashi (ed.), The Future of Bioethics: International Dialogues, Oxford, Oxford University Press, 2014, pp. 697–702.

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  1. Centre for Human Bioethics, School of Philosophical, Historical and International Studies, Monash University, Menzies Building, 20 Chancellors Walk, Melbourne, VIC, 3800, Australia

    Justin Oakley

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Oakley, J. Virtue Ethics and Public Policy: Upholding Medical Virtue in Therapeutic Relationships as a Case Study. J Value Inquiry 50, 769–779 (2016). https://doi.org/10.1007/s10790-016-9580-7

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