OBJECTIVE: How outside factors affect physician decision making remains an open question of vital importance. We sought to investigate the importance of various influences on physician decision making when clinical guidelines differ from patient preference. -/- METHODS: An online survey asking 469 primary care providers (PCPs) across four practice sites whether they would order magnetic resonance imaging for a patient with uncomplicated back pain. Participants were randomized to one of four scenarios: a patient's preference for imaging (control), a patient's (...) preference plus a colleague's opinion against imaging (colleague), a patient's preference plus a professional society's recommendation against imaging (profession), or a patient's preference plus an accountable care organization's quality metric that measures physician use of imaging (ACO). Demographic information and the reasoning behind participants' decisions also were obtained. -/- RESULTS: A total of 168 PCPs completed the survey, yielding a 36% completion rate. A majority chose not to pursue imaging: control 68%, colleague 85%, profession 87%, and ACO 78%. Multivariate logistic regression revealed that participants were more likely not to order advanced imaging only when reminded of a professional society recommendation (P = 0.017). Regression also suggested that practice site exerted an effect on the primary outcome. Evidence-based medicine and clinical judgment were the most cited reasons for the decision. -/- CONCLUSIONS: Our results reinforce the potential to leverage professional societies to advance evidence-based medicine and reduce unnecessary testing. At the same time, practice site appeared to exert influence, suggesting that these recommendations must be part of local institutional culture to be effective. (shrink)

The purpose of this paper is to elaborate on the notion of clinical medicine as a hermeneutical enterprise and to bridge the gap between the general perspectives of hermeneutics and the particularities of medical practice. The case of a patient with low back pain is analyzed. The discussion centers around the metaphor of the patient as a text and a model of five social discourses about low back pain. The problems addressed are: (1) the nature of a moral (...) experience, (2) the variety of available texts, (3) the difference between the doctor's and patient's narratives, and (4) the patient's and doctor's responsibility regarding the existential, biographical meaning of an illness. Although many problems are left unsolved, it is argued that from a philosophical point of view the notion of medicine as a hermeneutical enterprise opens up the possibility of gaining insight in the foundations of the clinical encounter. (shrink)

The use of deception in medical care is highly suspect in this country. Yet there is one condition for which deception is often used as a diagnostic tool. Nonepileptic seizures, a psychiatric condition in which emotional or psychological conflicts manifest themselves unconsciously through bodily symptoms, are currently diagnosed by a procedure called “provocative saline infusion.” The test is fundamentally deceptive, requiring the physician to intentionally and directly lie to the patient, causing the patient to believe that the administered solution caused (...) his seizures. Without such deception, the test might be useless. (shrink)

End-of-life decision making is fraught with ethical challenges. Withholding or withdrawing life support therapy is widely considered ethical in patients with high treatment burden, poor premorbid status, or significant projected disability even when such treatment is not “futile.” Whether such withdrawal of therapy in the aftermath of attempted suicide is ethical is not well established in the literature. We provide a clinical vignette and propose criteria under which such withdrawal would be ethical. We suggest that it is appropriate to (...) withdraw life support, regardless of the cause of the critical illness or disability, when the following criteria are met: Surrogates request withdrawal of care and the adequacy of surrogates is confirmed, an external reasonability standard is met, passage of time, perhaps 72 hours, to allow certainty regarding the patient's wishes, and psychiatric morbidity should be considered as grounds for withdrawal only in truly treatment-refractory cases. Fundamentally, we believe the question to ask is, “If this were not an attempted suicide, would a request to withdraw care be reasonable?” We believe that under these circumstances, such withdrawal of life support, even in an individual who has attempted suicide, does not constitute physician assistance with suicide and is distinct from physician aid-in-dying in several important respects. (shrink)

End-of-life decision making is fraught with ethical challenges. Withholding or withdrawing life support therapy is widely considered ethical in patients with high treatment burden, poor premorbid status, or significant projected disability even when such treatment is not ?futile.? Whether such withdrawal of therapy in the aftermath of attempted suicide is ethical is not well established in the literature. We provide a clinical vignette and propose criteria under which such withdrawal would be ethical. We suggest that it is appropriate to (...) withdraw life support, regardless of the cause of the critical illness or disability, when the following criteria are met: (1) Surrogates request withdrawal of care and the adequacy of surrogates is confirmed, (2) an external reasonability standard is met, (3) passage of time, perhaps 72 hours, to allow certainty regarding the patient's wishes, and (4) psychiatric morbidity should be considered as grounds for withdrawal only in truly treatment-refractory cases. Fundamentally, we believe the question to ask is, ?If this were not an attempted suicide, would a request to withdraw care be reasonable?? We believe that under these circumstances, such withdrawal of life support, even in an individual who has attempted suicide, does not constitute physician assistance with suicide and is distinct from physician aid-in-dying in several important respects. (shrink)

End-of-life decision making is fraught with ethical challenges. Withholding or withdrawing life support therapy is widely considered ethical in patients with high treatment burden, poor premorbid status, or significant projected disability even when such treatment is not “futile.” Whether such withdrawal of therapy in the aftermath of attempted suicide is ethical is not well established in the literature. We provide a clinical vignette and propose criteria under which such withdrawal would be ethical. We suggest that it is appropriate to (...) withdraw life support, regardless of the cause of the critical illness or disability, when the following criteria are met: Surrogates request withdrawal of care and the adequacy of surrogates is confirmed, an external reasonability standard is met, passage of time, perhaps 72 hours, to allow certainty regarding the patient's wishes, and psychiatric morbidity should be considered as grounds for withdrawal only in truly treatment-refractory cases. Fundamentally, we believe the question to ask is, “If this were not an attempted suicide, would a request to withdraw care be reasonable?” We believe that under these circumstances, such withdrawal of life support, even in an individual who has attempted suicide, does not constitute physician assistance with suicide and is distinct from physician aid-in-dying in several important respects. (shrink)

In this article, the authors attempt to build a bridge between economic theory and medical ethics to offer a new perspective to tackle ethical challenges in the physician–patient encounter. They apply elements of new institutional economics to the ethically relevant dimensions of the physician–patient relationship in a descriptive heuristic sense. The principal–agent theory can be used to analytically grasp existing action problems in the physician–patient relationship and as a basis for shaping recommendations at the institutional level. Furthermore, the patients’ (...) increased self-determination and modern opportunities for the medical laity to inform themselves lead to a less asymmetrical distribution of information between physician and patient and therefore require new interaction models. Based on the analysis presented here, the authors recommend that, apart from the physician’s necessary individual ethics, greater consideration should be given to approaches of institutional ethics and hence to incentive systems within medical ethics. (shrink)

This essay argues that Berger and Mohr’s A Fortunate Man (1967) – comprising social observation and photographs of the rural practitioner, Dr. Sassall and his patients – enacts an embodied, intersubjective empathy called “pain-work.” The book enacts “pain-work” through two strategies. Firstly, by conflating three ways of seeing – Berger’s observation, Mohr’s photography, and Sassall’s medical gaze – it shows that the clinical encounter embodies objective vision through intersubjective pain. Secondly, it employs the concepts of recognition and witnessing to (...) show how the subjectivity of the physician is distributed in his community. Thus, Berger and Mohr witness Sassall’s witnessing of his patients; even as Sassall and his patients are constituted intersubjectively, so too are Berger, Mohr, and Sassall. (shrink)

Like most EM physicians presented with a wide assortment of patients I've never seen before, will probably never see again, and cannot schedule for a more convenient return visit when there are not three ambulances pulling up to the door, I sometimes get a bit cranky when I interview a patient who has registered for a less‐than‐valid “emergency.” As a resident in Mel Konner's Becoming a Doctor put it, “Low back pain? Low fucking back pain? You're waking (...) me up for low fucking back pain?” Although I ceased a long time ago to ask, “Why now?”—you almost never get an answer that is satisfying—I still think it. Often, I am sad to say. Perhaps it is a result of the obvious forces of callousness born of distance born of training and of stress. Again, Konner captures it well: “It is obvious … that the stress of clinical training alienates the doctor from the patient, that in a real sense the patient becomes the enemy. … At first I believed that this was an inadvertent and unfortunate concomitant of medical training, but I now think that it is intrinsic. Not only stress and sleeplessness but the sense of the patient as the cause of one's distress contributes to the doctor's detachment.” Such detachment can blinker our eyes from seeing why patients come to the emergency room and prevent our ears from hearing. (shrink)

A review of the philosophical debate on theoretical models for the physician-patient relationship over the past fifteen years may point to some of the more productive questions for future research. Contractual models have been criticized for promoting a legalistic and minimalistic image of the relationship, such that another form of model (such as convenant) is required. Shifting from a contractual to a contractarian model (in keeping with Rawls' notion of an original position) provides an adequate response to many criticisms of (...) this type. A deeper criticism, however, is one that advocates a shift to a virtue-based approach. A creative amalgam between a contractarian model and elements of the virtue-based approach, combined with appropriate empirical investigation, may yield richer models in the future. (shrink)

Chronic back pain (CBP) is a leading cause of disability and results in considerable socio-economic burdens worldwide. Although CBP patients are commonly diagnosed and treated with a focus on the ‘end organ dysfunction’ (i.e., peripheral nerve injuries or diseases), the evaluation of CBP remains flawed and problematic with great challenges. Given that the peripheral nerve injuries or diseases are insufficient to define the etiology of CBP in some cases, the evaluation of alterations in the central nervous system becomes (...) particularly necessary and important. With the development of advanced neuroimaging techniques, extensive studies have been carried out to identify the cortical abnormalities in CBP patients. Here, we provide a comprehensive overview on a series of novel findings from these neuroimaging studies to improve our understanding of the cortical abnormalities originated in the disease. First, CBP patients normally exhibit central sensitization to external painful stimuli, which is indexed by increased pain sensitivity and brain activations in pain-related brain regions. Second, long-term suffering from chronic pain leads to emotional disorders, cognitive impairments, and the abnormalities of the relevant brain networks among CBP patients. Third, CBP is associated with massive cortical reorganization, including structural, functional, and metabolic brain changes. Overall, a deep insight into the neural mechanisms underlying the development and outcome of CBP through more sophisticated neuroimaging investigations could not only improve our current understanding of the etiology of CBP but also facilitate the diagnosis and treatment of CBP based on precision medicine. (shrink)

Low‐back pain can be invalidating physically as well as mentally. Despite professional help to treat and prevent low‐back pain, the pain often persists, and so do the problems related to low‐back pain. An intervention that made it possible for a significant part of patients with low‐back pain to improve health and well‐being raised the question: Why was it possible to help some and not others? The aim of the present paper was to achieve a deeper (...) understanding of factors patients experienced as helpful in professional support related to low‐back pain. This was explored using a hermeneutic‐phenomenological approach while analysing 20 interviews with patients with low‐back pain purposively chosen interviews conducted in relation to the intervention. An analysis was made using Ricoeur's interpretation theory. Data on both positive and negative experiences were read and reflected upon. We found that healthcare professionals’ adoption of a narrative approach facilitating the patient's perspective was perceived as helpful. Patients experienced this as being taken seriously; an experience that could be explained at a deeper, more nuanced level using Heidegger's philosophy. Facilitating the patient's perspective was conditional not only on the professional obtaining access to the patient's perspective but also on understanding and acknowledging the patient's existence. The challenge for healthcare professionals in this respect is to bridge the gap between the consultation's fact‐focused concern with the medical implications of low‐back pain and the patient's concern with the implications low‐back pain has for his or her personal identity and life. Listening to the patient's perspective in itself supports the subjective recovery process, while also supporting the quality of patient‐centred support and strengthening the patient's trust in its helpfulness. (shrink)

Chronic low back pain affects 50-80% of the population, while its consequences may impair the functioning of patients suffering from it, in many spheres of life. Hope is a factor which may influence coping with pain as well as cognitive reflection of pain experience. The aim of the study has been to check: 1) whether dependencies exist between hope-trait and hope-state and the perception of pain; 2) whether experiencing pain at the time of filling questionnaires matters for the (...) assessment of the level of hope; 3) whether there is interaction between hope, the pain experienced at the moment of investigation, and memory of the intensity of previously experienced pain. 150 patients participated in the study, they all reported aggravation of the chronic low back pain syndrome. The study was a cross-sectional study, based on questionnaires. On the third day of treatment the subjects were given the following questionnaires: Trait Hope Scale, State Hope Scale, and Numerical Rating Scale of Pain to fill. Poor correlation was demonstrated to exist between hope-state and hope-pathways on the one hand, and the intensity of minimum pain level experienced during the first three days of treatment. It has been noted that the presence of pain at the time of filling questionnaires results in reducing the hope-state, but only in those persons, who had experienced severe pain previously. On the other hand, in case of patients who had experienced slight pain previously, the pain present when filling in the questionnaires is conducive to enhanced hope-state. The results of the study confirm the complex character of relations between hope and pain. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Moral Distress for the Physician AssistantSharyn L. KurtzMy morning rounds as an inpatient medical oncology physician assistant began as usual. I arrived at the hospital early to receive 7 a.m. sign out from the covering resident. The overnight report began favorably. All patients remained stable. Even my patient, whom I will call Mrs. Walker,* had a quiet night. However, given her tenuous admission presentation, including altered mental status, (...) hypercalcemia (high levels of calcium in the blood), atrial fibrillation with rapid ventricular response (irregular, rapid heart function), widespread metastatic lung cancer, and recent neurosurgery to stabilize her spine, I decided to prioritize Mrs. Walker’s morning evaluation.Examining her medical chart proved reassuring. Her tachycardia (rapid heart rate) had been better controlled over the past two days. Her hypercalcemia had been treated, such that she was no longer somnolent. In fact, she was now arousable, conversant, and able to offer some input regarding her healthcare wishes. However, because she was experiencing intermittent delirium, her husband continued to act as her primary medical decision–maker.As her health care proxy, Mr. Walker had experienced conflict with the medical team during his wife’s prior hospital admission. However, even though Mr. Walker lived greater than 45 minutes from the hospital and was not able to visit regularly, he and I spoke daily by phone, which allowed me the opportunity to offer regular medical updates. Mr. Walker felt overwhelmed with his wife’s condition, but he was comfortable with the care the medical team had provided thus far. He was encouraged by the small improvements we had noted since her hospital admission five days prior.Mr. Walker stated on hospital admission that he wished for DNR/I orders to be placed, since this cohered with his wife’s previously stated wishes. However, he still wanted “everything else done” in terms of treating his wife’s medical conditions, including treatment of her atrial fibrillation, pain, and electrolyte anomalies. Most of all, he hoped Mrs. Walker would soon have increased mobility, which he felt would grant his wife the best quality of life possible. He was adamant that “being active” was what Mrs. Walker wished for, and that she had never wanted to be confined to bed.Mr. Walker’s requests seemed reasonable. Although Mrs. Walker’s lung cancer was widespread, and although many on the medical team felt she would not improve to the point where palliative chemotherapy could be considered, [End Page E13] she had stabilized. Her recent spine surgery had been successful, and she was healing adequately. The neurosurgeons had cleared Mrs. Walker for increased activity out of bed as soon as she could be fitted with a lumbar brace. The pain and palliative care specialists felt that Mrs. Walker’s residual back pain and delirium could be well managed with oral medications.Prior to my entering Mrs. Walker’s room to begin her physical evaluation, I was met by her seasoned nurse, whom I will call Amy. “Sharyn,” Amy warned, “Mrs. Walker’s heart rate is 150 and she is complaining of chest pain.” I entered Mrs. Walker’s room, and she was notably uncomfortable, grasping her chest. The monitor showed that Mrs. Walker’s heart rate was in fact in the 150’s. She was pale, short of breath, and wheezing. “Mrs. Walker,” I asked, “how severe is your chest pain on a scale from 1 to 10?” Mrs. Walker replied, “Nine.” I asked Amy to obtain an EKG, to provide oxygen, and to administer an IV medication that would slow Mrs. Walker’s heart rate. I stepped out of the room to place the computer orders, and I paged my attending physician to let him know about Mrs. Walker’s change in status. After hearing the update, my attending physician, whom I will call Dr. Clark, stated that he agreed with all of my treatment decisions thus far. He was on his way into the hospital. I planned out my next steps with him on the phone and returned to the patient’s room.The monitor gave evidence that Mrs. Walker’s heart rate was improving. Mrs. Walker reported that her pain was now “4 out of... (shrink)

Introduction Patients require an accurate knowledge about placebos and their possible effects to ensure consent for placebo-controlled clinical trials is adequately informed. However, few previous studies have explored patients’ baseline levels of understanding and knowledge about placebos. The present online survey aimed to assess knowledge about placebos among patients with a history of back pain. Design A 15-item questionnaire was constructed to measure knowledge about placebos. Additional questions assessed sociodemographic characteristics, duration and severity of back (...) pain, and previous experience of receiving placebos. Setting Participants recruited from community settings completed the study online. Results 210 participants completed the questionnaire. 86.7% had back pain in the past 6 months, 44.3% currently had back pain. 4.3% had received a placebo intervention as part of a clinical trial and 68.1% had previously read or heard information about placebos. Overall knowledge of placebos was high, with participants on average answering 12.07 of 15 questions about placebos correctly. However, few participants correctly answered questions about the nocebo effect and the impact of the colour of a placebo pill. Conclusions The findings identified key gaps in knowledge about placebos. The lack of understanding of the nocebo effect in particular has implications for the informed consent of trial participants. Research ethics committees and investigators should prioritise amending informed consent procedures to incorporate the fact that participants in the placebo arm might experience adverse side effects. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:My Patient, TeacherMarissa BlumI remember meeting Beatriz about 12 years ago when security was called to her office visit room by the fellow doctor-in-training who was seeing her. She was yelling loudly about her pain medications, causing a terrific commotion. I stepped in to relieve the fellow and tried to calm her down and move the visit along without anyone getting hurt or further upset. And from then on, (...) Beatriz was moved to my schedule from the fellow's for her monthly visits for her knee pain and refills of fentanyl and oxycodone. She had terrible knees and walked with a cane, almost always accompanied by her son. At one point, she came to our clinic asking to be seen but couldn't, and then fell onto her knees and rolled onto her back in the wait-room, clutching and waiving her cane, expelling expletives and railing at anyone who wanted to help but denying them that privilege. It was as though she relished exposing her pain and a lifetime of hardship for all to confront. I came down from my office to talk with her and when I couldn't convince her to get up on her own, we called EMS to assist and they took her away in an ambulance.For the first few years, I recoiled seeing her name on my schedule each month. I knew I would have to endure a barrage of labile emotions and complaints not just about her constant pain and feelings of inadequacy of her pain medications, but also about her other doctors and how they don't respond to her, or about how the rest of her family shows no care for her. Initially, these visits were hard because they were unpredictable and Beatriz also had bipolar disorder and maybe borderline personality too. I never knew which type of Beatriz I would walk in to see: Angry, tearful, lamentful, and all of those faces were difficult for me. But we met every month for years. During those visits, which almost always were attended by her son, who quietly sat by to either gently rebuff or passively agree with her, I learned so much about her and her very hard life. She was left to raise two children alone, unskilled and ill with hepatitis C, which led to liver cancer, followed later by breast cancer. She chose not to pursue additional therapy for breast cancer, expressing a fatalistic view of her life and intimating she in some way deserved the ailments that she developed. She saw me for disabling knee and hip arthritis that took away her independence and ability to scale the outdoor steps to her second-floor apartment and required the assistance of her son to dress, bathe and care for her. Beatriz never knew this, and I didn't share [End Page 18] it with her, but on one of my early morning drives into North Philadelphia, I saw her on a sun-baked unfriendly street, struggling to move around with her walker. She had many reasons to be angry, and the 30 minutes I spent with her every month became a catharsis for her to unload all that she felt.During my medical training, I encountered hundreds of patients—mostly all in the hospital setting—who might be characterized as difficult and understandably; no one who is relegated to the hospital setting, acutely or chronically ill and requiring inpatient care, could possibly be in the best mood of their lives. Somehow, it was easier for me to care for patients in these snapshot encounters that I controlled. I dictated my time in the room and didn't necessarily have to encounter the same challenging patient longitudinally, which made certain encounters much easier to bear. I realize now I wasn't fully processing the burdens carried by these patients in a way that enabled me to be a compassionate and fully present physician to them. It was an adaptation to the fast-paced life of residency, where one just has to get the job done and move on to the next task without time to process or reflect on difficult patient interactions. This is a... (shrink)

The sense of shame is part of human nature. What, then, is the role and significance of such a particular sensation, one that causes mental anxiety in a sick person’s weakest and the most vulnerable state? We know from historical documents going back as far as ancient Greece and Egypt that respecting patient privacy should be regarded as a moral duty for physicians in charge of treatment. However much today’s healthcare may have changed compared to centuries past, we note (...) that patient privacy has not lost its importance. In the current healthcare system, digital recording of private information and images enables others, in principle, to access these personal data quite easily. While we cannot reject the advantages offered by modern medicine, we need to consider how to design a healthcare system that respects patient privacy. What should be the standards of privacy in emergency services where urgent decisions and interventions have to be made? How should we guarantee patient privacy during medical education? The chapters of this book approach questions like these from the perspectives of different disciplines. The writings illustrate the increasing complexity of patient privacy issues in modern healthcare systems, particularly the growing difficulty to protect confidential data. At the same time, we can observe that patients are becoming more aware of their rights and their sensitivity in this area has increased. In our opinion, an approach that requires us to choose between the two values –health and privacy – would be wrong. Therefore, the question we should focus on is: “what kind of healthcare system should be developed to ensure the greatest respect for humans’ natural right to privacy?” If we want to answer this question and find sustainable solutions for these problems, it is crucial to use a multidisciplinary approach. From this perspective, the present volume is a first contribution to be published in Turkey to pursue this aim, including articles offered from various disciplines. (shrink)

RATIONALE: The concept of evidence-based medicine is important in providing efficient health care. The process uses research findings as the basis for clinical decision making. Evidence-based practice helps optimize current health care and enables the practitioners to be suitably accountable for the interventions they provide. Little work has been undertaken to examine how allied health professionals change their clinical practice in light of the latest evidence. The use of opinion leaders to disseminate new evidence around the management of low (...) class='Hi'>back pain into practice has been proposed. AIMS: The aim of this study was to investigate if physiotherapists' clinical management of patients with low back pain would change following an evidence-based education package, which utilized local opinion leaders and delivered the best evidence. METHOD: Thirty musculoskeletal physiotherapists from a Community Trust in North Staffordshire were cluster randomized by location of work, to two groups. The intervention group received an evidence-based programme on the management of low back pain, including advice regarding increasing activity levels and return to normal activity and challenging patients' fears and beliefs about their pain. The control group received a standard in-service training package on the management of common knee pathologies. The physiotherapists' clinical management of patients with low back pain was measured prior to training and 6 months post training. Outcome measures were based on physiotherapists completing 'discharge summary' questionnaires, which included information relating to the use and importance of therapies for treating their low back pain patients. RESULTS: There were few significant differences in treatment options between the intervention and control groups post training. Whilst there was some indication that physiotherapists were already utilizing aspects of psychosocial management for patients with low back pain, there was little change in what physiotherapists perceived to be important to patient recovery and actual clinical practice following the intervention. CONCLUSIONS: Psychosocial factors have been identified as an important factor in the recovery of patients with low back pain. This project incorporated the latest evidence on the management of low back pain and utilized the theory of opinion leaders to disseminate this evidence into clinical practice. Whilst there were some limitations in the overall size of the study, the results help to give an insight into the challenges faced by the health care system and researchers alike to ensure quality evidence is actually utilized by practitioners for the benefits of patient care. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Pain in the Patient’s KneeMary Jacobus* (bio)We know very little about pain either.—Sigmund Freud, Inhibitions, Symptoms, and AnxietyPain cannot be absent from the personality.—Wilfred Bion, The Elements of Psycho-AnalysisBetween Therapy and HermeneuticsWhat is the place of a psychoanalysis that exists “between” therapy (considered both as a theory and a practice, but also as a theory of practice) and hermeneutics, or the theory of interpretation and understanding? How do (...) we understand psychoanalytic “understanding” itself, as a mental process that involves both the analyst and the analysand in the analytic encounter? I want to approach these related questions by way of the writing of the British psychoanalyst Wilfred Bion (1897–1979). Bion is best known outside the psychoanalytic profession as a pioneer of the so-called leaderless group and a theorist of group process [see Bion, Experiences in Groups]. But his collected theoretical and clinical oeuvre represents—especially in its “epistemological” period during the early 1960s, from Learning from Experience (1962) to Transformations (1965)—the most systematic, original, and philosophical revision of psychoanalytic theory since Melanie Klein’s controversial development of Freudian ideas during the middle decades of this century.1 Consequently, Bion’s influence pervades, and in some cases underpins, the rethinking of psychoanalytic theory and practice that characterizes British object relations in the wake of Klein. In particular, it gives contemporary post-Kleinian analysis its distinctive focus on (not) learning, (non)meaning, and (un)knowing, with an accompanying emphasis on the destruction of the links that make thought possible, as well as on the importance of being able to learn from experience and being able to bear not knowing. In other words, it brings to the fore difficulties associated specifically with questions involving interpretation and understanding in an analytic context.Bion’s writing is noted for its paradoxical combination of directness and difficulty, and for its emphasis on primitive emotional states and experiences, on the one hand, and epistemology and consciousness, on the other. Rigorous in its clinical focus, it also makes [End Page 99] frequent reference to philosophy, mathematics, and other branches of contemporary science. André Green, in the context of the new impetus that Bion gave to orthodox Kleinianism by linking it back to Freud, suggests that his particular contribution lay in realizing that the unconscious phantasies and archaic anxieties emphasized by Klein coincided with thought processes. Finding in Bion “an author who could measure up to Lacan,” Green saw the two as engaged in the common project of “reformulating psychoanalytic theory within a contemporary epistemological framework.” But for Green, “Lacan made the error of excessive abstraction, whereas Bion, with his constant reference to affect and the process of transformation, is the more authentically intellectual” [10–11].2 Although Bion’s writing is read wherever the theory and practice of British object relations psychoanalysis is seriously taught and studied, for the most part it remains surprisingly unknown within the academy. This is especially the case in America—even when it comes to literary critics and theorists with an interest in the “authentically intellectual,” who are often, by contrast, steeped in Lacan and well versed in recent Continental psychoanalytic writing. If only for this reason, but also because Bion’s work is particularly relevant to issues involving the relation between therapy and hermeneutics, I want to focus on the culminating book of Bion’s “epistemological” period during the early 1960s, Transformations—so called because of Bion’s analogy between the psychoanalyst’s representation of the experience of the analytic encounter and the artist’s transformation of the experience of what he sees.Bion’s writing, although terse and at times humorous, makes considerable demands on the reader, particularly on the capacity of the mind to entertain a new thought or consider it from a radically new perspective. He places pressure on thinking (including his own), as well as attempting to communicate the seeming incomprehensibility or hallucinatory dimensions of psychotic thought processes (which are often continuous with normal thought processes). In what follows, I will address both the kind of communication made by Bion himself—which is subject to its own interpretive difficulties and obscurities—and the relation between therapy... (shrink)

Although bioethics is a lively and expanding interdisciplinary field, there is not enough research about the patient‐doctor relationship, a central issue in philosophy of medicine. This article surveys the state of the field, paying attention to recent work by Alfred Tauber, and supplementing it with insights from Hans Jonas's philosophy of technology in order to propose a principle of responsible autonomy for health care. Based on a comparative look across different sub‐fields in bioethics, the resulting model claims that physician responsibility (...) is essential to professional integrity, providing an alternative to other active trends emphasizing patient autonomy, such as Robert Veatch's contractual model. (shrink)

Although bioethics is a lively and expanding interdisciplinary field, there is not enough research about the patient‐doctor relationship, a central issue in philosophy of medicine. This article surveys the state of the field, paying attention to recent work by Alfred Tauber, and supplementing it with insights from Hans Jonas's philosophy of technology in order to propose a principle of responsible autonomy for health care. Based on a comparative look across different sub‐fields in bioethics, the resulting model claims that physician responsibility (...) is essential to professional integrity, providing an alternative to other active trends emphasizing patient autonomy, such as Robert Veatch's contractual model. (shrink)

Although bioethics is a lively and expanding interdisciplinary field, there is not enough research about the patient-doctor relationship, a central issue in philosophy of medicine. This article surveys the state of the field, paying attention to recent work by Alfred Tauber, and supplementing it with insights from Hans Jonas's philosophy of technology in order to propose a principle of responsible autonomy for health care. Based on a comparative look across different sub-fields in bioethics, the resulting model claims that physician responsibility (...) is essential to professional integrity, providing an alternative to other active trends emphasizing patient autonomy, such as Robert Veatch's contractual model. (shrink)

“It was the best of times. It was the worst of times.” Charles Dickens easily could have been describing our time and the dilemma in which victims of nonmalignant chronic pain find themselves.I am a forty-six-year-old registered nurse who specializes in oncology care and education. I am also a patient who suffers from chronic nonmalignant pain, and this malady has been the most frightening, the most humiliating, and the most difficult ordeal of my life.The morning of February 1983 severed my (...) life into “before” and “after,” as clearly as if it has been cut by a sharp knife. The “before” included my career as an oncology nurse, a college nursing professor, and a writer; but that was abruptly ended by the catastrophic rupture of a deep cerebral aneurysm. Surgery saved my life, but something unforeseen occurred during the procedure; and so, in the “after,” I have had to live with a serious seizure disorder and memory loss. (shrink)

“It was the best of times. It was the worst of times.” Charles Dickens easily could have been describing our time and the dilemma in which victims of nonmalignant chronic pain find themselves.I am a forty-six-year-old registered nurse who specializes in oncology care and education. I am also a patient who suffers from chronic nonmalignant pain, and this malady has been the most frightening, the most humiliating, and the most difficult ordeal of my life.The morning of February 1983 severed my (...) life into “before” and “after,” as clearly as if it has been cut by a sharp knife. The “before” included my career as an oncology nurse, a college nursing professor, and a writer; but that was abruptly ended by the catastrophic rupture of a deep cerebral aneurysm. Surgery saved my life, but something unforeseen occurred during the procedure; and so, in the “after,” I have had to live with a serious seizure disorder and memory loss. (shrink)

A discussion of Christian ethics focuses on the physician's image as a parent, warrior against death, expert, and teacher, and the oath that guides his or her practice.

Research documents that many chronic non-malignant pain patients experience existential, spiritual and religious needs; however, research knowledge is missing on if and how physicians approach these needs. We conducted a systematic review to explore the extent to which physicians address these needs in their communication with chronic non-malignant pain patients and to explore the facilitators and challenges of this communication. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, searching Embase, Medline, Scopus and PsycINFO. The (...) quality of the included articles was assessed based on design-specific screening tools. We included four of 2337 screened articles and found the quality to be good. Physicians’ communication about existential, spiritual and religious needs was given low priority and depended on the patients’ own initiative, except when clinicians were interested in holistic care. Patient dissatisfaction with the physician’s attention to these needs was related to higher pain and depression. Physicians’ challenges for addressing these needs were their tendency to prioritize physiological aspects and close further elaboration of existential needs when addressed by the patients. The main facilitator was the individual physician’s willingness to listen with openness and empathy to the patients’ existential concerns. A tentative conclusion is that physicians rarely meet the existential, spiritual and religious needs of their chronic non-malignant pain patients. This might be due to higher priority of physical aspects, lack of time and a lack of knowledge about the importance of and training in the ability to address these needs. Further research is needed on physicians’ communication about existential, spiritual and religious needs and on their training in here. (shrink)

Physicians have long aided their patients in dying in an effort to ease human suffering. It is only in the nineteenth and twentieth centuries that the prolongation of life has taken on new meaning due to the powers now available to physicians, through new drugs and high technology interventions. Whereas earlier physicians and patients could readily acknowledge that nothing further could be done, today that judgment is problematic.Most often, aiding the dying took the form of not doing anything (...) further to prolong life. Morally, this act of restraint was not difficult, because few options could have been considered. However, some physicians, rarely, would help patients die either by hastening death directly or by increasing pain control with the risk of hastening death, the so-called double effect. When directly hastening death, physicians either directly caused the death of the patient through euthansia, or supplied the means to the patient to bring about death with or without encouragement to use these means. The latter is physician-assisted suicide. (shrink)

Physicians have long aided their patients in dying in an effort to ease human suffering. It is only in the nineteenth and twentieth centuries that the prolongation of life has taken on new meaning due to the powers now available to physicians, through new drugs and high technology interventions. Whereas earlier physicians and patients could readily acknowledge that nothing further could be done, today that judgment is problematic.Most often, aiding the dying took the form of not doing anything (...) further to prolong life. Morally, this act of restraint was not difficult, because few options could have been considered. However, some physicians, rarely, would help patients die either by hastening death directly or by increasing pain control with the risk of hastening death, the so-called double effect. When directly hastening death, physicians either directly caused the death of the patient through euthansia, or supplied the means to the patient to bring about death with or without encouragement to use these means. The latter is physician-assisted suicide. (shrink)

Objective Gather information from physicians about factors contributing to unnecessary noninvasive imaging and impact of possible solutions. Methods Qualitative study of 14 physicians using a phenomenological approach and the Theoretical Domains Framework. Results Most participants self-reported that >10% of the imaging tests they order are unnecessary. External sources of pressure included: peer-review, patient demands, nursing expectations, specialist requests, as well as prior experience with patient advocates, and the compensation and pension system. Internal sources of pressure included reliance on anecdote, self-doubt (...) about diagnoses, and fear of missing a diagnosis and of professional liability. Participants expressed both optimism and concern about potential solutions, such as adopting decision support software. Conclusion Physicians are under pressure from multiple sources to order unnecessary imaging. Peer review, nursing expectations, and perceptions about Veteran compensation and pension are newly reported contributing factors. (shrink)

Fibromyalgia is a chronic pain syndrome characterized by dysfunctional processing of nociceptive stimulation. Neuroimaging studies have pointed out that pain-related network functioning seems to be altered in these patients. It is thought that this clinical symptomatology may be maintained or even strengthened because of an enhanced expectancy for painful stimuli or its forthcoming appearance. However, neural electrophysiological correlates associated with such attentional mechanisms have been scarcely explored. In the current study, expectancy processes of upcoming laser stimulation (painful and non-painful) (...) and its further processing were explored by event-related potentials (ERPs). Nineteen fibromyalgia patients and twenty healthy control volunteers took part in the experiment. Behavioral measures (reaction times and subjective pain perception) were also collected. We manipulated the pain/no pain expectancy through an S1–S2 paradigm (cue-target). S1 (image: triangle or square) predicted the S2 appearance (laser stimulation: warmth or pinprick sensation). Laser stimuli were delivered using a CO2 laser device. Temporal and spatial principal component analyses were employed to define and quantify the ERP component reliability. Statistical analyses revealed the existence of an abnormal pattern of pain expectancy in patients with fibromyalgia. Specifically, our results showed attenuated amplitudes at posterior lCNV component in anticipation of painful stimulation that was not found in healthy participants. In contrast, although larger P2 amplitudes to painful compared to innocuous events were shown, patients did not show any amplitude change in this laser-evoked response as a function of pain predictive cues (as occurred in the healthy control group). Additionally, analyses of the subjective perception of pain and reaction time indicated that laser stimuli preceded by pain cues were rated as more painful than those signaling non-pain expectancy and were associated with faster responses. Differences between groups were not found. The present findings suggest the presence of dysfunction in pain expectation mechanisms in fibromyalgia that eventually may make it difficult for patients to correctly interpret signs that prevent pain symptoms. Furthermore, the abnormal pattern in pain expectancy displayed by fibromyalgia patients could result in ineffective pain coping strategies. Understanding the neural correlates of pain processing and its modulatory factors is crucial to identify treatments for chronic pain syndromes. (shrink)

Physicians’ fear of criminal prosecution for prescribing opioid analgesics is a major reason why many chronic pain patients are having an increasingly difficult time obtaining medically appropriate pain relief. In Ruan v. United States, 142 S. Ct. 2370 (2022), the Supreme Court unanimously vacated two federal convictions under the Controlled Substances Act. The Court held that the government must prove that the defendant knowingly or intentionally acted in an unauthorized manner.

The pinnacle of the physician's clinical skills is his ability to develop the autonomy of his patients in the management of their health affairs. To do this requires the forging of a relationship in which patients' attitudes toward their health and illness are products of the doctor-patient relationship rather than unilateral behavior by either one. Modern medicine is beset with problems that make it difficult for physicians to develop and exercise the skills that lead to patient autonomy. An (...) erosion of public confidence in physicians is being caused by several mojar forces that include: (1) the power of science over life; (2) medical technology's dehumanizing effect; (3) legalization of medical ethics; and (4) industrialization and commercialization of medical care. To restore the kind of confidence that makes the physician an effective proponent of his patient's autonomy will require a major emphasis upon all aspects of medical ethics in the medical curriculum and in medical practice. Clinical investigation of this subject is highly appropriate. Clinical faculties should be developed in greater numbers who are authorities in the humanities as well as in science. Our medical schools need also to develop and to utilize models of health care in which relations with patients are personalized, continuous, and comprehensive so that ethical ideals such as patient autonomy can be demonstrated by precept and example, and can also be researched. (shrink)

Previous studies examining EEG and LORETA in patients with chronic pain discovered an overactivation of high theta and low beta power in central regions. MEG studies with healthy subjects correlating evoked nociception ratings and source localization described delta and gamma changes according to two music interventions. Using similar music conditions with chronic pain patients, we examined EEG in response to two different music interventions for pain. To study this process in-depth we conducted a mixed-methods case study approach, based (...) on three clinical cases. Effectiveness of personalized music therapy improvisations versus preferred music on chronic pain was examined with 16 participants. Three patients were randomly selected for follow-up EEG sessions three months post-intervention, where they listened to recordings of the music from the interventions provided during the research. To test the difference of EM versus preferred music, recordings were presented in a block design: silence, their own composed EM, preferred music, and a non-participant’s EM as a control. Participants rated their pain before and after the EEG on a 1–10 scale. We conducted a detailed single case analysis to compare all conditions, as well as a group comparison of entrainment-healing condition versus preferred music condition. Power spectrum and according LORETA distributions focused on expected changes in delta, theta, beta, and gamma frequencies, particularly in sensory-motor and central regions. Intentional moment-by-moment attention on the sounds/music rather than on pain and decreased awareness of pain was experienced from one participant. Corresponding EEG analysis showed accompanying power changes in sensory-motor regions and LORETA projection pointed to insula-related changes during entrainment-pain music. LORETA also indicated involvement of visual-spatial, motor, and language/music improvisation processing in response to his personalized EM which may reflect active recollection of creating the EM. Group-wide analysis showed common brain responses to personalized entrainment-healing music in theta and low beta range in right pre- and post-central gyrus. We observed somatosensory changes consistent with processing pain during entrainment-healing music that were not seen during preferred music. These results may depict top–down neural processes associated with active coping for pain. (shrink)

Next SectionPublic and healthcare professionals differ in their attitudes towards euthanasia and physician-assisted suicide (PAS), the legal status of which is currently in the spotlight in the UK. In addition to medical training and experience, religiosity, locus of control and patient characteristics (eg, patient age, pain levels, number of euthanasia requests) are known influencing factors. Previous research tends toward basic designs reporting on attitudes in the context of just one or two potentially influencing factors; we aimed to test the comparative (...) importance of a larger range of variables in a sample of nursing trainees and non-nursing controls. One hundred and fifty-one undergraduate students (early-stage nursing training, late-stage nursing training and non-nursing controls) were approached on a UK university campus and asked to complete a self-report questionnaire. Participants were of mixed gender and were on average 25.5 years old. No significant differences in attitude were found between nursing and non-nursing students. There was a significant positive correlation between higher religiosity and positive attitude toward euthanasia (r=0.19, p<0.05) and a significant negative relationship between internal locus of control and positive attitude toward PAS (r=−0.263, p<0.01). Multivariate analyses revealed differing predictor models for attitudes towards euthanasia and PAS, and confirm the importance of individual differences in determining these attitudes. The unexpected direction of association between religiosity and attitudes may reflect a broader cultural shift in attitudes since earlier research in this area. Furthermore, these findings suggest it possible that experience, more than training itself, may be a bigger influence on attitudinal differences in healthcare professionals. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Criminal Law, Pain Relief, and Physician Aid in DyingFaye Girsh, Ed.D., Executive DirectorMadam:The article by Cantor and Thomas on “Pain Relief, Acceleration of Death, and Criminal Law” (KIEJ, June 1996) was a tortured attempt to develop criteria for the humane and compassionate physician who tries to serve the needs of a patient in unremitting pain. There are three areas that merit comment.The authors dealt with pain medications that might (...) have the undesirable side effect of causing death. They did not mention tolerance, which usually occurs in a patient with chronic pain and which would require exceedingly high doses to be effective. They did not mention barbiturates, which are preferable to opiates in causing death and which are used increasingly by compassionate physicians to answer the pleas of their suffering patients, but for which there is no excuse about alleviating pain. Would the criminal law just call the prescription of a lethal dose of barbiturates a reckless act and require conviction? Fortunately, juries, as the authors point out, do not balance these formulas on the head of a pin. When they see the circumstances under which these doctors do help their patients, they choose to nullify the law and would ignore the suggestions made in this article.The authors refer to the “consent” of the patient. They do not mention that these doctors are operating with more than consent; they are administering these medications because suffering patients are begging them to put them out of their pain and the indignities of the dying process. The article discusses the process as though it were the same as consent to elective surgery. These patients—with AIDS, cancer, and hopeless neurological degeneration—are not simply agreeing to a procedure; they are desperately seeking a way out. If the criminal law were to develop criteria for physician aid in dying, certainly one of them should be the active, witnessed, repeated request of such a patient for a certain, quick, painless, gentle death.The third point is that physicians do not face prosecution when administering no treatment to a patient whose life could be saved with treatment but who chooses not to receive it. This has been upheld by the U.S. Supreme Court; no criteria for suffering, alternatives, terminality, justifiability, or unbearability are required. The doctor can stand by while the patient dies what may be a protracted, difficult death, but it is within the law. What matters in this situation is the decision of the patient to refuse treatment, and that is absolute. How ironic that the patient who cannot refuse treatment must, with his or her doctor, jump through all these hoops to achieve a peaceful death.One worries that the physician who must balance the risk of “risky pain relief” against the accusation of recklessness will err in the direction of allowing [End Page 103] the patient to bear the pain rather than help with a dose of analgesics that might be considered beyond the stipulated “risk.”Why don’t we just be honest about it? Allow dying or hopelessly ill patients to make the decision about what they want by passing a carefully defined law allowing euthanasia rather than balancing the risk and trying to determine the “purpose” of the physician’s ministrations. We protect some patients from themselves while allowing others almost complete autonomy to make the choice of ending their lives. The authors were right in saying that proponents of rational laws consider this sheer hypocrisy.Faye Girsh, Executive DirectorHemlock Society U.S.A. Denver, COFaye Girsh misconceives our article’s objective as an “attempt to develop criteria” for the humane physician. Our goal in writing the paper was to analyze the current criminal law framework in the hope of sharpening debate and engendering normative critiques. We readily acknowledge tensions in the current legal framework and would support changes in that framework.Copyright © 1997 The Johns Hopkins University Press... (shrink)

Patientenmobilität und grenzüberschreitende Gesundheitsversorgung sind alltägliche Phänomene in der Europäischen Union (EU). Im Jahr 2011 hat die EU eine Richtlinie erlassen, um in diesem Kontext Rechtssicherheit herzustellen. Bisher gibt es keine umfassenden systematischen Studien über ethische Aspekte grenzübergreifender Gesundheitsversorgung. In dieser Arbeit werden die rechtlichen Entwicklungen der grenzübergreifenden Gesundheitsversorgung dargestellt und die in der Literatur vereinzelt erwähnten ethisch relevanten Aspekte heuristisch und auf Patiententypologien aufbauend systematisch inventarisiert und diskutiert. Es zeigt sich, dass die Möglichkeit der Patientenmobilität und die damit vor (...) allem verbundenen Finanzierungsregelungen die Autonomie einiger Patienten sicherlich verbessern kann. Allerdings können wohl nicht alle Patienten Versorgungsverbesserungen erwarten. Im Gegenteil können sogar negative Konsequenzen für einige Patienten folgen, was vor allem aus gerechtigkeitstheoretischen Überlegungen kritisch zu sehen ist. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Criminal Law, Pain Relief, and Physician Aid in DyingFaye Girsh, Ed.D., Executive DirectorMadam:The article by Cantor and Thomas on “Pain Relief, Acceleration of Death, and Criminal Law” (KIEJ, June 1996) was a tortured attempt to develop criteria for the humane and compassionate physician who tries to serve the needs of a patient in unremitting pain. There are three areas that merit comment.The authors dealt with pain medications that might (...) have the undesirable side effect of causing death. They did not mention tolerance, which usually occurs in a patient with chronic pain and which would require exceedingly high doses to be effective. They did not mention barbiturates, which are preferable to opiates in causing death and which are used increasingly by compassionate physicians to answer the pleas of their suffering patients, but for which there is no excuse about alleviating pain. Would the criminal law just call the prescription of a lethal dose of barbiturates a reckless act and require conviction? Fortunately, juries, as the authors point out, do not balance these formulas on the head of a pin. When they see the circumstances under which these doctors do help their patients, they choose to nullify the law and would ignore the suggestions made in this article.The authors refer to the “consent” of the patient. They do not mention that these doctors are operating with more than consent; they are administering these medications because suffering patients are begging them to put them out of their pain and the indignities of the dying process. The article discusses the process as though it were the same as consent to elective surgery. These patients—with AIDS, cancer, and hopeless neurological degeneration—are not simply agreeing to a procedure; they are desperately seeking a way out. If the criminal law were to develop criteria for physician aid in dying, certainly one of them should be the active, witnessed, repeated request of such a patient for a certain, quick, painless, gentle death.The third point is that physicians do not face prosecution when administering no treatment to a patient whose life could be saved with treatment but who chooses not to receive it. This has been upheld by the U.S. Supreme Court; no criteria for suffering, alternatives, terminality, justifiability, or unbearability are required. The doctor can stand by while the patient dies what may be a protracted, difficult death, but it is within the law. What matters in this situation is the decision of the patient to refuse treatment, and that is absolute. How ironic that the patient who cannot refuse treatment must, with his or her doctor, jump through all these hoops to achieve a peaceful death.One worries that the physician who must balance the risk of “risky pain relief” against the accusation of recklessness will err in the direction of allowing [End Page 103] the patient to bear the pain rather than help with a dose of analgesics that might be considered beyond the stipulated “risk.”Why don’t we just be honest about it? Allow dying or hopelessly ill patients to make the decision about what they want by passing a carefully defined law allowing euthanasia rather than balancing the risk and trying to determine the “purpose” of the physician’s ministrations. We protect some patients from themselves while allowing others almost complete autonomy to make the choice of ending their lives. The authors were right in saying that proponents of rational laws consider this sheer hypocrisy.Faye Girsh, Executive DirectorHemlock Society U.S.A. Denver, COFaye Girsh misconceives our article’s objective as an “attempt to develop criteria” for the humane physician. Our goal in writing the paper was to analyze the current criminal law framework in the hope of sharpening debate and engendering normative critiques. We readily acknowledge tensions in the current legal framework and would support changes in that framework.Copyright © 1997 The Johns Hopkins University Press... (shrink)

The aim of this study was to investigate factors associated with seriously ill patients’ preferences for their family and physicians making resuscitation decisions on their behalf. Using SUPPORT II data, the study revealed that, among 362 seriously ill patients who were experiencing pain, 277 (77%) answered that they would want their family and physicians to make resuscitation decisions for them instead of their own wishes being followed if they were to lose decision-making capacity. Even after controlling for other (...) variables, patients who preferred the option of undergoing cardiopulmonary resuscitation (CPR) in the future were twice as likely, and those who had had ventilator treatment were four-fifths less likely, to rely on their family and physicians than those who did not want CPR (odds ratio (OR)-2.28; 95% confidence interval (CI) 1.18-4.38) or those who had not received ventilator treatment (OR-0.23; 95% CI 0.06-0.90). Psychological variables (anxiety, quality of life, and depression), symptomatic variables (severity of pain and activities of daily living) and the existence of surrogates were not significantly associated with patients’ preferences for having their family and physicians make resuscitation decisions for them. Age was not a significant factor for predicting the decision-making role after controlling for other variables. (shrink)

At the end of life, pain management is commonly a fundamental part of the treatment plan for patients where curative measures are no longer possible. However, the increased recognition of opioid diversion for secondary gain coupled with efforts to treat patients in the home environment towards the end of life creates the potential for ethical dilemmas in the palliative care management of terminal patients in need of continuous pain management. We present the case of an end-stage patient (...) with rectal cancer who required a continuous residential narcotic infusion of fentanyl for pain control due to metastatic disease. His functional status was such that he had poor oral intake and ability to perform other activities of daily living, but was able to live at home with health agency nursing care. The patient presented to this institution with a highly suspect history of having lost his fentanyl infusion in a residential accident and asking for a refill to continue home therapy. The treating physicians had concerns of diversion of the infusion medication by caregivers and were reluctant to continue the therapeutic relationship with the patient. This case exemplifies the tension that can exist between wanting to continue with palliative care management of an end-stage patient and the fear of providers when confronted by evidence of potential diversion of opioid analgesic medications. We elucidate how an ethical framework based on a combination of virtue and narrative/relationship theories with reference to proportionality can guide physicians to a pragmatic resolution of these difficult situations. (shrink)

This paper presents a procedure designed to aid physicians and patients in the process of making medical decisions, and illustrates its implementation to aid pregnant women, who decided to undergo prenatal diagnostic test choose a physician to administer it. The procedure is based on a medical decision-making model of Karni (J Risk Uncertain 39: 1–16, 2009). This model accommodates the possibility that the decision maker’s risk attitudes may vary with her state of health and incorporates other costs, such as (...) pain and inconvenience, associated with alternative treatments. The medical decision problem was chosen for its relative simplicity and the transparency it affords. (shrink)

One of the most difficult decisions a clinician may face is when, if ever, to decline what a patient wants, based on the clinician’s own moral conscience. Regardless of what the clinician decides, the outcome may be deeply emotionally painful for both parties, and the pain may last. I will discuss this pain, how it occurs, and what we can do to try to reduce it before, during, and after a conflict arises. Approaches include explaining how we are like the (...) patient or doctor, that no one is perfect, and that what we do is not who we are. (shrink)

Uncertainty regarding potential disciplinary action may give physicians pause when considering whether to accept a chronic pain patient or how to treat a patient who may require long-term or high doses of opioids. Surveys have shown that physicians fear potential disciplinary acrion for prescribing controlled substances and that physicians will, in some cases, inadequately prescribe opioids due to fear of regulatory scrutiny. Prescribing opioids for long-term pain management, particularly noncancer pain management, has been controversial; and boards have investigated and, in (...) some cases, disciplined physicians for such prescribing. While in virtually all of these cases the disciplinary actions were successfully appealed, news of the success was not often as well-publicized as news of the disciplinary actions, leaving some physicians confused about their potential liability when prescribing opioids for pain. The confusion has perhaps increased as a result of two relatively recent cases, one where a physician was successfully disciplined by a state medical board for undertreatment of his patients’ pain, and another where the physician was successfully sued for inadequate pain treatment. (shrink)

This paper examines whether physician-assisted suicide is morally permissible, and whether it should be legalised in the sense that those seeking or performing such procedure will be immune from prosecution. The issues of moral and legal permissibility1 are closely connected. One way to argue for the permissibility of PAS is grounded in the argument that a patient has the right to refuse life-saving equipment, or to have it withdrawn,2 and then to further argue that there is no relevant distinction between (...) refusal/withdrawal and PAS, if the patient consents. This is essentially the argument raised in “The Philosophers’ Brief ”, filed by six distinguished philosophers. However, this argument has been soundly criticised. Frances Kamm points out that the general claim on which Dworkin et al. rely—that there is no moral difference per se between killing and letting die—is false. This is because a patient has the right to refuse treatment even when this is against his interest because the alternative would be forced treatment, but it is not true to say that a patient has the right to PAS even when it is against his interest. Also at issue is the Doctrine of Double Effect, according to which there is a moral distinction between an action that is intended to cause death and one that is merely foreseen to cause death. [End Page 224] In section I of this paper, I shall argue against DDE, which purports to disallow PAS but not refusal/withdrawal. I shall argue that since it is permissible for a physician to prescribe morphine to a patient suffering excruciating pain, it is also permissible for her to prescribe such a drug to a patient suffering pain, with the intention that he be killed and hence relieved of the suffering. The grounds on which I rely is the thesis that intention is irrelevant to permissibility, as proposed by Judith Thomson and T.M. Scanlon. In section II, I shall discuss David Velleman’s argument that termination of life is morally impermissible. I proceed to examine in section III the theoretical version of the Slippery Slope Argument. In section IV, I shall consider the practical version of the Slippery Slope Argument. In section V, I shall discuss other consequentialist objections to the legalisation of PAS. In the final section, I shall consider the view that even if PAS is morally permissible, it does not follow that it should be legalised. The argument I consider is the consequentialist one that legalising PAS may have a very different significance—when we consider the total consequences—than if there is only a single act of PAS, considered in isolation. While I agree that consequences are generally very important, I shall argue that we should approach the issue from a contractualist rather than a utilitarian perspective.3. (shrink)

In the present paper, we evaluate the grounds on which therapeutic approaches are determined in elderly demented patients as a typical group of patients who are conscious but lack the ability to make competent judgments. It is argued that none of the factors that the patient as an individual being has at present and that are complete in that individual - the age of the patient, dementia, personhood, and the ability to feel pain - is likely to be (...) a genuine reason for care-providers including health care workers and patient’s family to discontinue the treatment for severely demented patients. It is also claimed that reasons for discontinuation of the treatment for severely demented patients arise from the relationship between the patient and the care-providers, especially the patient’s family. The human relationships between the patient and the family may be maintained as long as the latter find some significance in the presence of the severely demented patient and recognize him/her as “one of them”. When the patient ceases to be “one of them” for the family and is excluded from “their company”, the reason for supporting the demented member of the family is lost. The benefit to the patient and the value of his/her presence lose the individuality or specificity and are subjected to interpretation by the family. Therefore, the reason for discontinuation of the treatment for a severely demented patient is termination of the relationship between the patient and his/her family. The significance of our conclusion is briefly discussed. (shrink)