Currently, the common theoretical models of "preferred" decision-making relationships do not correspond well with clinical experience. This interview study of congestive heart failure (CHF) patients documents the variety of patient preferences for decision-making, and the necessity for attention to family involvement. In addition, these findings illustrate the confusion as to the designation of surrogate decision-makers and physicians in charge. We conclude that no single model of physician-patient decision-making should be preferred, and that physicians should first ask patients how they (...) want medical information and decision-making to be handled. (shrink)
Substantial efforts have recently been made to reform the physician-patient relationship, particularly toward replacing the `silent world of doctor and patient' with informed patient participation in medical decision-making. This 'new ethos of patient autonomy' has especially insisted on the routine provision of informed consent for all medical interventions. Stronly supported by most bioethicists and the law, as well as more popular writings and expectations, it still seems clear that informed consent has, at best, been received in a lukewarm fashion (...) by most clinicians, many simply rejecting what they commonly refer to as the `myth of informed consent'. The purpose of this book is to defuse this seemingly intractable controversy by offering an efficient and effective operational model of informed consent. This goal is pursued first by reviewing and evaluating, in detail, the agendas, arguments, and supporting materials of its proponents and detractors. A comprehensive review of empirical studies of informed consent is provided, as well as a detailed reflection on the common clinician experience with attempts at informed consent and the exercise of autonomy by patients. In the end, informed consent is recast as a management tool for pursuing clinically and ethically important goods and values that any clinician should see as meriting pursuit. Concurrently, the model incorporates a flexible, anticipatory approach that recognizes that no static, generic ritual can legitimately pursue the quite variable goods and values that may be at stake with different patients in different situations. Finally, efficiency of provision is addressed by not pursuing the unattainable and ancillary. Throughout, the traditional principle of beneficence is appealed to toward articulating an operational model of informed consent as an intervention that is likely to change outcomes at the bedside for the better. (shrink)
Charles Taylor's retrieval of an expressivist understanding of persons, and of language as constitutive of meaning, contains promising insights for restoring moral connectedness between patients and physicians.
In this companion volume to their 1981 work, A Philosophical Basis of Medical Practice, Pellegrino and Thomasma examine the principle of beneficence and its role in the practice of medicine. Their analysis, which is grounded in a thorough-going philosophy of medicine, addresses a wide array of practical and ethical concerns that are a part of health care decision-making today. Among these issues are the withdrawing and withholding of nutrition and hydration, competency assessment, the requirements for valid surrogate decision-making, quality-of-life determinations, (...) the allocation of scarce health care resources, medical gatekeeping, and for-profit medicine. The authors argue for the restoration of beneficence to its place as the fundamental principle of medical ethics. They maintain that to be guided by beneficence a physician must perform a right and good healing action which is consonant with the individual patient 's values. In order to act in the patient 's best interests, or the patient 's good, the physician and patient must discern what that good is. This knowledge is gained only through a process of dialogue between patient and/or family and physician which respects and honors the patient 's autonomous self-understanding and choice in the matter of treatment options. This emphasis on a dialogical discernment of the patient 's good rejects the assumption long held in medicine that what is considered to be the medical good is necessarily the good for this patient. In viewing autonomy as a necessary condition of beneficence, the authors move beyond a trend in the medical ethics literature which identifies beneficence with paternalism. In their analysis of beneficence, the authors reject the current emphasis on rights- and duty-based ethical systems in favor of a virtue-based theory which is grounded in the physician- patient relationship. This book's provocative contributions to medical ethics will be of great interest not only to physicians and other health professionals, but also to ethicists, students, patients, families, and all others concerned with the relationship of professional to patient and patient to professional in health care today. (shrink)
By considering the nature of the relationship between patient and healer, The Healing Bond explores the responsibilities of both, with a special emphasis on the therapeutic responsibility. The editors and contributors examine both orthodox and unorthodox forms of healing practice and apply a variety of professional and analytic perspectives to the medical profession as a whole. They look at specific areas of health such as midwifery, psychoanalysis, naturopathy, the relations between medicine and state, and the appeal of "quacks." Particular (...) issues of current concern are also discussed, including medical litigation, codes of ethics among complementary practitioners and cooperation between orthodox and complementary medicine practitioners. Contributors: Mary Douglas, Calliope Farsides, David Peters, Roy Porter, Richenda Power, Margaret Stacey, Robert Sumerling, and Gillian Vanhegan. (shrink)
Decision making is a key activity, perhaps the most important activity, in the practice of healthcare. Although physicians acquire a great deal of knowledge and specialised skills during their training and through their practice, it is in the exercise of clinical judgement and its application to individual patients that the outstanding physician is distinguished. This has become even more relevant as patients become increasingly welcomed as partners in a shared decision making process. This book translates the research and theory from (...) the science of decision making into clinically useful tools and principles that can be applied by clinicians in the field. It considers issues of patient goals, uncertainty, judgement, choice, development of new information, and family and social concerns in healthcare. It helps to demystify decision theory by emphasizing concepts and clinical cases over mathematics and computation. (shrink)
Practically every development in medicine in the post–World War II period distanced the physician and the hospital from the patient and the community, disrupting personal connections and severing bonds of trust. We need an ethics that include bodily mediated knowledge as a complement to intellectual knowledge. Care is a challenging concept to explore, in part because it is employed widely and often without thoughtful parsing. Moreover, it has gained increasing significance in ethical discourse.1 Since the 1980s, feminist theorists have used (...) the term care ethics to describe a relational approach to morality that does not rely on rubrics of adjudication such as rules or consequences. The .. (shrink)
The puzzling case of the broken arm -- Hernias, diets, and drugs -- Why physicians cannot know what will benefit patients -- Sacrificing patient benefit to protect patient rights -- Societal interests and duties to others -- The new, limited, twenty-first-century role for physicians as patient assistants -- Abandoning modern medical concepts: doctor's "orders" and hospital "discharge" -- Medicine can't "indicate": so why do we talk that way? --"Treatments of choice" and "medical necessity": who is fooling whom? -- Abandoning informed (...) consent -- Why physicians get it wrong and the alternatives to consent: patient choice and deep value pairing -- The end of prescribing: why prescription writing is irrational -- The alternatives to prescribing -- Are fat people overweight? -- Beyond prettiness: death, disease, and being fat -- Universal but varied health insurance: only separate is equal -- Health insurance: the case for multiple lists -- Why hospice care should not be a part of ideal health care I: the history of the hospice -- Why hospice care should not be a part of ideal health care II: hospice in a postmodern era -- Randomized human experimentation: the modern dilemma -- Randomized human experimentation: a proposal for the new medicine -- Clinical practice guidelines and why they are wrong -- Outcomes research and how values sneak into finding of fact -- The consensus of medical experts and why it is wrong so often. (shrink)
This “Legal Briefing” column covers recent legal developments involving patient decision aids. This topic has been the subject of recent articles in JCE. It is included in the 2010 Patient Protection and Affordable Care Act. And it has received significant attention in the biomedical literature, including a new book, a thematic issue of Health Affairs, and a recent article in the New England Journal of Medicine. Moreover, physicians and health systems across the United States are increasingly integrating decision aids into (...) their clinical practice. Both federal and state laws play a significant role in promoting this expanded use. On the other hand, concerns about liability could stymie development and implementation. We categorize legal developments concerning patient decision aids into the following five sections:1. Development of decision aids2. Effectiveness of decision aids3. Federal regulation of decision aids4. State regulation of decision aids5. Legal concerns regarding decision aids. (shrink)
In the last of the group of papers from the conference on inatrogenic disease which we are publishing is this issue Katharine Whitehorn told the audience mainly of doctors and doctors in training - and tells many more through this Journal - what the patient expects from them. She envisages a generation of doctors who are coming to see their role rather differently from that of their fathers, and perhaps in the future a new medical scene.
Here is a thoroughly updated edition of a classic in palliative medicine. Two new chapters have been added to the 1991 edition, along with a new preface summarizing where progress has been made and where it has not in the area of pain management. This book addresses the timely issue of doctor-patient relationships arguing that the patient, not the disease, should be the central focus of medicine. Included are a number of compelling patient narratives. Praise for the first edition "Well (...) written. . .should be read by everyone in medical practice or considering a career in medicine."---JAMA. "Memorable passages, important ideas, and critical analysis. This is a book that clinicians and educators should read."---New England Journal of Medicine. (shrink)
Power is an inescapable aspect of all socialrelationships, and inherently is neither goodnor evil. Doctors need power to fulfil theirprofessional obligations to multipleconstituencies including patients, thecommunity and themselves. Patients need powerto formulate their values, articulate andachieve health needs, and fulfil theirresponsibilities. However, both parties canuse or misuse power. The ethical effectivenessof a health system is maximised by empoweringdoctors and patients to develop `adult-adult'rather than `adult-child' relationships thatrespect and enable autonomy, accountability,fidelity and humanity. Even in adult-adultrelationships, conflicts and complexitiesarise. Lack of (...) concordance between doctors andpatients can encourage paternalism but may bebest resolved through negotiated care. Afurther area of conflict involves the `doubleagency' of doctors for both patients and thecommunity. Empowerment of all players is notalways possible but is most likely where eachparty considers and acknowledges power issues. (shrink)
Some critiques of cybermedicine claim that it is problematic because it fails to create physician–patient relationships. But, electronically mediated encounters do create such relationships. The issue is the nature and quality of those relationships and whether they are conducive to good patient care and meet the ethical ideals and standards of medicine. In this paper, I argue that effective communication and compassion are, in most cases, necessary for the establishment of trusting and morally appropriate physician–patient relationships. The creation of these (...) relationships requires patients and physicians to take psychological and emotional risks and to make commitments to each other. The problem is that by altering the form and content of verbal and non-verbal behaviors and by limiting the kinds of interactions that can take place, cybermedicine makes risk-free interactions easier and more commonplace and retards the development of physician compassion and patient trust. In doing so, cybermedicine encourages morally inappropriate physician–patient relationships. I argue that Merleau-Ponty''s notion of embodiment and Kierkegaard''s criticisms of disinterested reflection help us to understand how cybermedicine can undermine patient health and well being and why it should be seen as a possible threat to the moral integrity of physician–patient relationships. (shrink)
In this paper, we explore the desires that play a role at the palliative stage and relate them to various approaches to patient autonomy. What attitude can physicians and other caregivers take to the desires of patients at the palliative stage? We examine this question by introducing five physicians who are consulted by Jackie, an imaginary patient with metastatic lung carcinoma. By combining the models of the physician-patient relationship developed by Emanuel and Emanuel (1992) and the Hellenistic approaches to (...) desires analyzed by Nussbaum (1994), five different ways of dealing with desires in the context of palliative care are sketched. The story of Jackie shows that desires are to a certain extent responsive to reasoning. In the palliative process, that can be a reason to devote attention to the desires of patients and caregivers and to determine which desires need to be fulfilled, which are less important, and how they are linked to emotions the patient has. (shrink)
Theoretical models for physician-patient communication in clinical practice are described in literature, but none of them seems adequate for solving the communication problem in clinical practice that emerges in case of factitious disorder. Theoretical models generally imply open communication and respect for the autonomy of the patient. In factitious disorder, the physician is confronted by lies and (self)destructive behaviour of the patient, who in one way or another tries to involve the physician in this behaviour. It is no longer (...) controversial that the physician should communicate his consideration of a factitious disorder without insistence that the patient accepts this diagnosis. However, the balance between patient autonomy and open communication on the one hand, and the preservation of the patient's health, physician integrity and of a constructive physician-patient relationship on the other is easily disrupted. In this article, an epistemological model is described to facilitate a positive outcome of confrontation in treatment of factitious disorder. Analysing the problem in terms of systems theory will help the physician to assess what information is appropriate to use in which phase of the patient's treatment, while preserving the physician-patient relationship. (shrink)
This article reviews and comments on the five categories of arguments used to defend zero tolerance with regard to sexual contacts resulting from the physician-patient relationship as summarised by Cullen. In addition it puts forward a hypothesis—“fear of loss by third party”—as a psychological explanation for the collective insistence on a zero tolerance policy.
Background: Physicians sometimes are asked by co-workers for prescriptions to deal with their medical problems. These “hallway” requests typically occur outside a formal doctor-patient relationship. There are professional guidelines on serving as physician for family members and friends, but no guidelines address writing prescriptions for co-workers. The frequency of these requests and the factors physicians consider in responding to them have not been examined.Objectives: To obtain data on the frequency of these requests and physicians’ attitudes and practices in responding to (...) them, and to explore the ethical considerations in writing prescriptions for co-workers.Design: A survey was administered to all physician faculty and residents in an academic department of internal medicine. The questions included whether the respondent had ever been asked for a prescription by a co-worker and how often the respondent had received such requests and written such prescriptions in the previous three months. Respondents also were asked to rate how likely they would be to write such a prescription in 15 hypothetical scenarios.Results: Of the 113 respondents who completed surveys, 68 percent reported having been asked for a prescription by a co-worker. Among those who had ever been asked, 59 percent had been asked one or more times during the previous three months and 88 percent had ever written such a prescription. Also, 88 percent of all respondents stated they were “very likely” or “likely” to write the prescription in one or more of the hypothetical scenarios.Conclusions: Most physicians in our sample had been asked for prescriptions by co-workers, and most had written such prescriptions. Many respondents indicated a willingness to write such prescriptions in a variety of scenarios, despite the absence of a formal doctor-patient relationship. Further discussion of the ethical considerations in writing prescriptions for co-workers is needed. (shrink)
Some of the human relations of doctor and patient, by D.L. Edsall.--The care of patients. Its psychological aspects, by C.F. Martin.--The medical education of Jones, by Smith, by W.S. Thayer.--The significance of illness, by A.F. Riggs.--Some psychological observations by the surgeon, by F. G. Balch.--Human nature and its reaction to suffering, by L.K. Lunt.--The care of the aged, by A. Worcester.--The care of the dying, by A. Worcester.--Attention to personality in sex hygiene, by A. Worcester.
Introduction: making the invisible visible -- The nobility of the material -- Research at war -- The guilded age of research -- The doctor as whistle-blower -- New rules for the laboratory -- Bedside ethics -- The doctor as stranger -- Life through death -- Commissioning ethics -- No one to trust -- New rules for the bedside -- Epilogue: The price of success.
Background Following passage of the Patient Self Determination Act in 1990, health care institutions that receive Medicare and Medicaid funding are required to inform patients of their right to make their health care preferences known through execution of a living will and/or to appoint a surrogate-decision maker. We evaluated the impact of external factors and perceived patient preferences on physicians’ decisions to honor or forgo previously established advance directives (ADs). In addition, physician views regarding legal risk, patients’ ability to comprehend (...) complexities involved with their care, and impact of medical costs related to end-of-life care decisions were explored. Methods Attendees of two Mayo Clinic continuing medical education courses were surveyed. Three scenarios based in part on previously court-litigated matters assessed impact of external factors and perceived patient preferences on physician compliance with patient-articulated wishes regarding resuscitation. General questions measured respondents’ perception of legal risk, concerns over patient knowledge of idiosyncrasies involved with their care, and impact medical costs may have on compliance with patient preferences. Responses indicating strength of agreement or disagreement with statements were treated as ordinal data and analyzed using the Cochran Armitage trend test. Results Three hundred eighty-eight of 951 surveys were completed (41% response rate). Eighty percent reported they were likely to honor a patient’s AD despite its 5 year age. Fewer than half (41%) would honor the AD of a patient in ventricular fibrillation who had expressed a desire to “pass away in peace.” Few (17%) would forgo an AD following a family’s request for continued resuscitative treatment. A majority (52%) considered risk of liability to be lower when maintaining someone alive against their wishes than mistakenly failing to provide resuscitative efforts. A large percentage (74%) disagreed that patients could not appreciate complexities surrounding their care while 69% agreed that costs should never impact a physician’s decision as to whether to comply with a patient’s AD. Conclusions Our findings highlight the impact, albeit small, external factors have on physician AD compliance. Most respondents based their decision on the clinical situation at hand and interpretation of the patient’s initial wishes and preferences expressed by the AD. (shrink)
Machine generated contents note: 1. Introduction: why focus on informed consent?; 2. Deciding who decides: capacity and consent; 3. Putting the informed into 'informed consent': information and decision-making; 4. Freedom of expression: the voluntary nature of consent; 5. A patient's prerogative? The continuing nature of consent; 6. Concluding words about consent; Index.
Background Ethically, informed consent regarding randomised controlled trials (RCTs) should be understandable to patients. The patients can then give free consent or decline to participate in a RCT. Little is known about what patients really understand in consultations about RCTs. Methods Cancer patients who were asked to participate in a randomised trial were surveyed using a semi-standardised interview developed by the authors. The interview addresses understanding, satisfaction and needs of the patients. The sample included eight patients who participated in a (...) trial and two who declined. The data were analysed on the basis of Mayring's qualitative analysis. Results Patients' understanding of informed consent was less developed than anticipated, especially concerning key elements such as randomisation, content and procedure of RCTs. Analysing the result about satisfaction of the patients, most of the patients described their consultations as hectic and without advance notice. Health limitations due to cancer played a decisive role. However, most of the patients perceived their physician to be sympathetic. Analysing the needs of patients, they ask for a clear informed consent consultation with enough time and adequate advance notice. Conclusion This study fills an important empirical research gap of what is ethically demanded in an RCT consultation and what is really understood by patients. The qualitative approach enabled us to obtain new results about cancer patients' understanding of informed consent, to clarify patients' needs and to develop new ideas to optimise the informed consent. (shrink)
Empathy is generally regarded as important and positive. However, descriptions of empathy are often inadequate and deceptive. Furthermore, there is a widespread lack of critical attention to such deficiencies. This critical review of the medical discourse of empathy shows that tendencies to evade and misrepresent the understanding subject are common. The understanding subject’s contributions to the empathic process are often neglected or described as something that can and should be avoided or controlled. Furthermore, the intrinsic and closely interwoven relationship between (...) medical understanding and empathy is generally not explored. Instead of challenging objectivistic and instrumental ideals, the medical discourse of empathy tends to accommodate to inadequate ideals of objectivity and instrumentalism. Thus, important aspects of physician’s rationality, understanding, and morality are neglected and important opportunities for reflection, dialogue, and critique are forfeited. Both the critical and constructive parts of this paper are heavily inspired by philosophical hermeneutic insights, e.g. that physician’s empathy is always historically situated and part of a moral commitment. At the end of this paper, an alternative description of empathy - i.e. appropriate understanding of another human being - is outlined to facilitate the inclusion of hermeneutic insights and accentuate the inherent relationship between empathy and morality. (shrink)
Medical error is a leading problem of health care in the United States. Each year, more patients die as a result of medical mistakes than are killed by motor vehicle accidents, breast cancer, or AIDS. While most government and regulatory efforts are directed toward reducing and preventing errors, the actions that should follow the injury or death of a patient are still hotly debated. According to Nancy Berlinger, conversations on patient safety are missing several important components: religious voices, traditions, and (...) models. In After Harm, Berlinger draws on sources in theology, ethics, religion, and culture to create a practical and comprehensive approach to addressing the needs of patients, families, and clinicians affected by medical error. She emphasizes the importance of acknowledging fallibility, telling the truth, confronting feelings of guilt and shame, and providing just compensation. After Harm adds important human dimensions to an issue that has profound consequences for patients and health care providers. (shrink)
Medical confidentiality is a core concept of professionalism and should be an integral part of pregraduate and postgraduate medical education. The aim of our study was to define the factors influencing attitudes towards patient confidentiality in everyday situations in order to define the need for offering further education to various subgroups of physicians. All internists and general practitioners who were registered members of the association of physicians in Geneva or who were working in the department of internal medicine or in (...) the medical polyclinic of the University Hospital of Geneva in 2004 received a standardised questionnaire. Physicians were asked to indicate for seven vignettes whether a violation of confidentiality had occurred and whether the violation was not important, important or serious (scores 1–3; no violation = 0). 508 completed questionnaires were returned (participation rate 55%). Physicians who had worked in the hospital for more than 20 years identified violations of confidentiality more often than physicians with less hospital experience. Binary logistic regression showed that ethics education, total years of professional experience, being an internist, having a private practice, the length of working in private practice and gender were factors associated with correct identification of violations and their severity. However, each factor played a specific role only for single cases or a small number of situations (Cronbach α <0.6). Postgraduate education programs on confidentiality should be offered to a wide range of physicians and should address specific hypothetical situations in which there is a risk of avoidable breaches of confidentiality. (shrink)
This is a review of the biographic drama Love and Mercy. More than a story of the evolution of The Beach Boys, it is the story of the lead Beach Boy, Brian Wilson, and his struggle with substance abuse, mental illness, family stress, emerging love, and a controlling psychologist. Interwoven are many bioethics themes, including the doctor–patient relationship, conflict of interest, autonomy, and patient welfare. For those unaware of the sadness and torment running directly alongside the sunny, bubbly life of (...) The Beach Boys, this film is an eye-opener. It is also a great reminder of the importance of boundaries between clinicians and their patients. (shrink)
We all know that doctors accept gifts from drug companies, ranging from pens and coffee mugs to free vacations at luxurious resorts. But as the former Editor-in-Chief of The New England Journal of Medicine reveals in this shocking expose, these innocuous-seeming gifts are just the tip of an iceberg that is distorting the practice of medicine and jeopardizing the health of millions of Americans today. In On the Take, Dr. Jerome Kassirer offers an unsettling look at the pervasive payoffs that (...) physicians take from big drug companies and other medical suppliers, arguing that the billion-dollar onslaught of industry money has deflected many physicians' moral compasses and directly impacted the everyday care we receive from the doctors and institutions we trust most. Underscored by countless chilling untold stories, the book illuminates the financial connections between the wealthy companies that make drugs and the doctors who prescribe them. Kassirer details the shocking extent of these financial enticements and explains how they encourage bias, promote dangerously misleading medical information, raise the cost of medical care, and breed distrust. Among the questionable practices he describes are: the disturbing number of senior academic physicians who have financial arrangements with drug companies; the unregulated "front" organizations that advocate certain drugs; the creation of biased medical education materials by the drug companies themselves; and the use of financially conflicted physicians to write clinical practice guidelines or to testify before the FDA in support of a particular drug. A brilliant diagnosis of an epidemic of greed, On the Take offers insight into how we can cure the medical profession and restore our trust in doctors and hospitals. (shrink)
Contemporary health care often lacks generosity of spirit, even when treatment is most efficient. Too many patients are left unhappy with how they are treated, and too many medical professionals feel estranged from the calling that drew them to medicine. Arthur W. Frank tells the stories of ill people, doctors, and nurses who are restoring generosity to medicine--generosity toward others and to themselves. The Renewal of Generosity evokes medicine as the face-to-face encounter that comes before and after diagnostics, pharmaceuticals, and (...) surgeries. Frank calls upon the Roman emperor Marcus Aurelius, philosopher Emmanuel Levinas, and literary critic Mikhail Bakhtin to reflect on stories of ill people, doctors, and nurses who transform demoralized medicine into caring relationships. He presents their stories as a source of consolation for both ill and professional alike and as an impetus to changing medical systems. Frank shows how generosity is being renewed through dialogue that is more than the exchange of information. Dialogue is an ethic and an ideal for people on both sides of the medical encounter who want to offer more to those they meet and who want their own lives enriched in the process. The Renewal of Generosity views illness and medical work with grace and compassion, making an invaluable contribution to expanding our vision of suffering and healing. (shrink)
Background There are numerous ethical challenges that can impact patients and families in the health care setting. This paper reports on the results of a study conducted with a panel of clinical bioethicists in Toronto, Ontario, Canada, the purpose of which was to identify the top ethical challenges facing patients and their families in health care. A modified Delphi study was conducted with twelve clinical bioethicist members of the Clinical Ethics Group of the University of Toronto Joint Centre for Bioethics. (...) The panel was asked the question, what do you think are the top ten ethical challenges that Canadians may face in health care? The panel was asked to rank the top ten ethical challenges throughout the Delphi process and consensus was reached after three rounds. Discussion The top challenge ranked by the group was disagreement between patients/families and health care professionals about treatment decisions. The second highest ranked challenge was waiting lists. The third ranked challenge was access to needed resources for the aged, chronically ill, and mentally ill. Summary Although many of the challenges listed by the panel have received significant public attention, there has been very little attention paid to the top ranked challenge. We propose several steps that can be taken to help address this key challenge. (shrink)
The aim of this book is to provide an accessible account of ethics in general practice, addressing concerns identified by practitioners. It contains many examples and allows the reader to gain practical insights into how to identify and analyze the ethical issues they encounter in everyday general practice.
Increasing European co-operation must take place in many areas, including medical ethics. Against the background of common cultural norms and pluralistic variation within political traditions, religion and lifestyles, Europe will have to converge towards unity within the field of medical ethics. This article examines how such convergence might develop with respect to four major areas: European research ethics committees, democratic health systems, the human genome project and rules for stopping futile treatments.
To precisely define wisdom has been an ongoing task of philosophers for millennia. Investigations into the psychological dimensions of wisdom have revealed several features that make exemplary persons "wise." Contemporary bioethicists took up this concept as they retrieved and adapted Aristotle's intellectual virtue of phronesis for applications in medical contexts. In this article, we build on scholarship in both psychology and medical ethics by providing an account of clinical wisdom qua phronesis in the context of the practice of psychoanalysis and (...) psychodynamic psychotherapy. With the support of qualitative data, we argue that the concept of clinical wisdom in mental healthcare shares several of the key ethical dimensions offered by standard models of phronesis in medical ethics and serves as a useful, albeit overlooked, reference point for a broader development of virtue-based medical ethics. We propose that the features of clinical wisdom are pragmatic skills that include, but are not limited to, an awareness of balance, the acceptance of paradox, and a particular clinical manner that maintains a deep regard for the other. We offer several suggestions for refining training programs and redoubling efforts to provide long-term mentorship opportunities for trainees in clinical mental healthcare in order to cultivate clinical wisdom. (shrink)
Palliative care is a recent branch of health care. The doctors, nurses, and other professionals involved in it took their inspiration from the medieval idea of the hospice, but have now extended their expertise to every area of health care: surgeries, nursing homes, acute wards, and the community. This has happened during a period when patients wish to take more control over their own lives and deaths, resources have become scarce, and technology has created controversial life-prolonging treatments. Palliative care is (...) therefore faced with more ethical problems that other areas of health care. This book, by a clinician, teacher, and writer on health care ethics, has been written to provide all those who care for the terminally ill--doctors, nurses, social workers, clergymen, physiotherapists--with the concepts and principles which will assist them with difficult decisions. It challenges many received doctrines of palliative care, but its well-illustrated central theme is that technical expertise must be controlled by humane, non-technical judgments. (shrink)
While ethicists have directed much attention to controversial biomedical issues--including euthanasia, abortion, and genetic engineering--they have largely ignored the less obvious, but more pervasive, everyday ethical problems faced by family physicians. Ethical Issues in Family Medicine addresses these problems, offering an ethics that reflects the distinctive features of family practice, and helping family physicians to appreciate the extent to which ethical issues influence their practice.
Placebos are allegedly used widely in general practice. Surveys reporting high level usage, however, have combined two categories, ‘pure’ and ‘impure’ placebos. The wide use of placebos is explained by the high level usage of impure placebos. In contrast, the prevalence of the use of pure placebos has been low. Traditional pure placebos are clinically ineffective treatments, whereas impure placebos form an ambiguous group of diverse treatments that are not always ineffective. In this paper, we focus on the impure placebo (...) concept and demonstrate problems related to it. We also show that the common examples of impure placebos are not meaningful from the point of view of clinical practice. We conclude that the impure placebo is a scientifically misleading concept and should not be used in scientific or medical literature. The issues behind the concept, however, deserve serious attention in future research. (shrink)
In the late twentieth century the impressive achievements of modern medicine are obvious, yet medicine seems to have failed to satisfy public expectation. Government regulation of hospitals and doctors is tightening in most Western countries and health funding is a divisive political issue. Medical complaints departments are increasingly busy. In the United States medical litigation has reached alarming levels, and a similar trend can be seen in other developed countries. Is there something wrong with medical research and practice? This book, (...) written by a surgeon with more than thirty years experience of clinical medicine, examines what it is that doctors do, and what it is that patients expect of them. It finds that in the face of uncertainty, expectation and reality ofen often diverge. Starting from the communication difficulties that exist between doctors and patients, Humane Medicine explores the roles of science, ethics and the humanities in medical practice. It forcefully argues that more science cannot heal this rift, nor can better education in ethics. To foster better communication, medical teachers must change their philosophy and methods, so that value-laden issues in clinical medicine are interwoven with the necessary science. Professor Little outlines some possible ways to achieve this. This important book will be of interest to medical students and their teachers, clinicians, health policy planners and other readers concerned about the direction of the medical profession. (shrink)