Search

The medical profession contains five "spheres of morality": clinical care, clinical research, scientific knowledge, population health, and the market. These distinct sets of normative commitments require physicians to act in different ways depending on the ends of the activity in question. For example, a physician-scientist emphasizes patients' well-being in clinic, prioritizes the scientific method in lab, and seeks to maximize shareholder returns as a board member of a pharmaceutical firm. Physicians increasingly occupy multiple roles in healthcare and move between them frequently, creating the possibility of conflict between the ethical obligations of their various roles. This paper examines the entire moral landscape of medicine through the lens of role morality. It develops a novel framework that helps physicians recognize how their moral commitments depend on the nature and context of the situation, clarifies ethical conflicts that physicians face, and concludes with ideas for resolving these conflicts. [ABSTRACT FROM AUTHOR]

While the clinical promise of much stem cell research remains largely theoretical, patients are nonetheless pursuing unproven stem cell therapies in jurisdictions around the world—a phenomenon referred to as “stem cell tourism.” These treatments are generally advertised on a direct-to-consumer basis via the Internet. Research shows portrayals of stem cell medicine on such websites are overly optimistic and the claims made are unsubstantiated by published evidence. However, anecdotal evidence suggests that parents are pursing these “treatments” for their children, despite potential physical and financial risk. Physicians are in a unique position as they can be expected to be involved in, or privy to, such decisions. In this paper, we consider what duties physicians may have toward minor patients whose parents/guardians wish to engage in stem cell tourism on their behalf. We use the Canadian perspective to address the broadly relevant issues raised by this trend. [ABSTRACT FROM AUTHOR]

Comments on a study by R. M. Werner and colleagues, which examined issues relating to the use of deception by physicians to get an insurance company to pay for a medical procedure. Percentage of physicians in the U.S. who had supported misrepresentation of facts given to insurance companies; Ethical implications of the deceptive approach to health insurance; Arguments concerning the health care system in the U.S.

The article presents the discussion on Russian military implicated in a systematic campaign of war crimes. Topics include Great Britain and the European Union placing sanctions upon a wide range of Russian individuals and institutions; and medical institutions having a longstanding history of cooperation with biomedical entities.

On February 3, 2010, a “Letter of Concern from Bioethicists,” organized by fetaldex.org, was sent to report suspected violations of the ethics of human subjects research in the off-label use of dexamethasone during pregnancy by Dr. Maria New. Copies of this letter were submitted to the FDA Office of Pediatric Therapeutics, the Department of Health and Human Services (DHHS) Office for Human Research Protections, and three universities where Dr. New has held or holds appointments. We provide a critical appraisal of the Letter of Concern and show that it makes false claims, misrepresents scientific publications and websites, fails to meet standards of evidence-based reasoning, makes undocumented claims, treats as settled matters what are, instead, ongoing controversies, offers “mere opinion” as a substitute for argument, and makes contradictory claims. The Letter of Concern is a case study in unethical transgressive bioethics. We call on fetaldex.org to withdraw the letter and for co-signatories to withdraw their approval of it. [ABSTRACT FROM AUTHOR]

In this article the author discusses aspects of the report "Is Continuous Sedation at the End of Life an Ethically Preferable Alternative to Physician-Assisted Suicide?," by K. Raus, S. Sterckx, and F. Mortier within the issue. He argues that Raus and colleagues' argument that continuous deep sedation (CDS) is not an appropriate alternative to physician-assisted suicide (PAS), which is based on four arguments, can be refuted relatively easily. A refutation of the four arguments is presented.

The article comments on a paper by Ronald Lindsay concerning his evaluation of the 10-year experience with the Oregon Death with Dignity Act. According to the author, Lindsay's evaluation focuses on the arguments that such a law would result in widespread abuses. The author criticizes the Oregon statute for involving physicians in assisted dying.

Discusses issues related to the gifts given by pharmaceutical companies to physicians and research grants based on a study by Dana Katz, Arthur L. Caplan and Jon F. Merz. Influence of the gifts on the prescribing behavior of physicians; Problems concerning accepting drug company grant funding; Implications of funding for the pharmaceutical industry.

An editorial is presented on arguments for physician aid-in-dying (PAD) for psychiatric disorders. Topics discussed include permitting PPAD would not have negative policy and practice implications serious enough to outweigh the intended merits; conflicts with the practice of involuntary commitment in psychiatry; and parity argument has the following form: If PAD for terminal physical illness is justified on the basis of suffering.

The article presents a study on physicians' education under the Physician Payments Sunshine Act (PPSA) as well as its significance on the improvement of patient trust in the U.S. Discussed are issues on conflicts of interest (COI) in medical journals and studies on transparency at the medical care sector. Challenges on medical policy under the PPSA are explored.

Neonatal intensive care units represent simultaneously one of the great success stories of modern medicine, and one of its most controversial developments. One particularly controversial issue is the resuscitation of extremely preterm infants. Physicians in the United States generally accept that they are required to resuscitate infants born as early as 25 weeks and that it is permissible to resuscitate as early as 22 weeks. In this article, I question the moral pressure to resuscitate by criticizing the idea that resuscitation in this context “saves” a human life. Our radical medical advancements have allowed us to intervene in the life of a human before it makes sense to say that such an intervention “saves” someone; rather, what the physician does in resuscitating and treating an extremely preterm infant is to take over creating it. This matters, I argue, because “rescues” are much more morally urgent than “creations.” [ABSTRACT FROM PUBLISHER]

The article discusses the article "Impairing Loyalty: Corporate Responsibility for Clinical Misadventure," by Kenneth Kipnis. In the article the authors offer their opinions on Kipnis' article on conflicts of interest which may occur as a result of relationships between physicians and corporations and on corporate responsibility in cases in which patients are harmed as a result of relationships between physicians and corporations that have promoted medicines or medical procedures.

The article discusses unacceptable risk in pregnancy. The author discusses aspects of the article "An Ethically Justified Framework for Clinical Investigation to Benefit Pregnant and Fetal Patients," by F. A. Chervenak and L. B. McCullough. Topics include an analysis of Chervenak and McCullough’s claims regarding the physician–patient relationship and whether it can support the stance that fetal mortality and morbidity are unacceptable outcomes in research intended to benefit pregnant women.

The article reflects on issues regarding the ethics of physician involvement in capital punishment discussed in the paper "The ethical elephant in the death penalty room," by Michael Keane. It discusses ethical issues on the death penalty and the role-specific rights and obligations of physicians in the medical profession.

Shortly before and during the Second World War, Japanese doctors and medical researchers conducted large-scale human experiments in occupied China that were at least as gruesome as those conducted by Nazi doctors. Japan never officially acknowledged the occurrence of the experiments, never tried any of the perpetrators, and never provided compensation to the victims or issued an apology. Building on work by Jing-Bao Nie, this article argues that the U.S. government is heavily complicit in this grave injustice, and should respond in an appropriate way in order to reduce this complicity, as well as to avoid complicity in future unethical medical experiments. It also calls on other U.S. institutions, in particular the Presidential Commission for the Study of Bioethical Issues, to urge the government to respond, or to at least inform the public and initiate a debate about this dark page of American and Japanese history. [ABSTRACT FROM AUTHOR]

Various kinds of alcohol and drug testing, such as preemployment, routine, and for-cause testing, are commonly performed by employers. While healthcare organizations usually require preemployment drug testing, they vary on whether personnel will be subjected to further testing. Recently, a call has gone out for postincident testing among physicians who are involved in serious, preventable events, especially ones leading to a patient's death. This article will offer a number of counterarguments to that proposal and discuss an alternate approach: that health institutions can better improve patient safety and employees’ well-being by implementing an organizational policy of “speaking up” when system operators notice work behaviors or environmental factors that threaten harm or peril. The article will conclude with a description of various strategies that facilitate speaking up, and why the practice constitutes a superior alternative to mandatory alcohol and drug testing in the wake of serious, harm-causing medical error. [ABSTRACT FROM PUBLISHER]

The article discusses conflicts and tensions between health care professionals, patients and their families in ethics consultations. Topics discussed include legal regime governing surrogate decision making as highly complex, pregnancy exclusions impacting health care providers in the exercise of their autonomy and professional judgment and ethicist providing guidance based on patient rights, principles and the family's narrative.

Sometimes physicians lie to third-party payers in order to grant their patients treatment they would otherwise not receive. This strategy, commonly known as gaming the system, is generally condemned for three reasons. First, it may hurt the patient for the sake of whom gaming was intended. Second, it may hurt other patients. Third, it offends contractual and distributive justice. Hence, gaming is considered to be immoral behavior. This article is an attempt to show that, on the contrary, gaming may sometimes be a physician's duty. Under specific circumstances, gaming may be necessary from the viewpoint of the internal morality of medicine. Moreover, the objections against gaming are examples of what we call the idealistic fallacy, that is, the fallacy of passing judgments in a nonideal world according to ideal standards. Hence, the objections are inconclusive. Gaming is sometimes justified, and may even be required in the name of beneficence. [ABSTRACT FROM AUTHOR]

An obituary for Dr. Jack Kevorkian is presented along with comments on medical bioethics and physician-assisted suicide.

The relatively new practice of continuous sedation at the end of life (CS) is increasingly being debated in the clinical and ethical literature. This practice received much attention when a U.S. Supreme Court ruling noted that the availability of CS made legalization of physician-assisted suicide (PAS) unnecessary, as CS could alleviate even the most severe suffering. This view has been widely adopted. In this article, we perform an in-depth analysis of four versions of this 'argument of preferable alternative.' Our goal is to determine the extent to which CS can be considered to be an alternative to PAS and to identify the grounds, if any, on which CS may be ethically preferable to PAS. [ABSTRACT FROM AUTHOR]

As the debate over how to manage or discourage physicians' financial conflicts of interest with the drug and medical device industries has become more heated, critics have questioned or dismissed the concept of 'conflict of interest' itself. A satisfactory definition relates conflict of interest to concerns about maintaining social trust and distinguishes between breaches of ethical duty and temptations to breach duty. Numerous objections to such a definition have been offered, none of which prevails on further analysis. Those concerned about conflicts of interest have contributed to misunderstandings, however, by failing to demonstrate when social arrangements leading to temptations to breach duties are in themselves morally blameworthy. Clarifying 'conflict of interest' is important if we are eventually going to develop productive modes of engagement between medicine and for-profit industry that avoid the serious ethical pitfalls now in evidence. [ABSTRACT FROM AUTHOR]

Using medical advances to enhance human athletic, aesthetic, and cognitive performance, rather than to treat disease, has been controversial. Little is known about physicians' experiences, views, and attitudes in this regard. We surveyed a national sample of physicians to determine how often they prescribe enhancements, their views on using medicine for enhancement, and whether they would be willing to prescribe a series of potential interventions that might be considered enhancements. We find that many physicians occasionally prescribe enhancements, but doctors hold nuanced and ambiguous views of these issues. Most express concerns about the potential effects of enhancements on social equity, yet many also believe specific enhancements that are safe and effective should be available but not covered by insurance. These apparently contradictory views might reflect inherent tensions between the values of equity and liberty, which could make crafting coherent social policies on medical enhancements challenging. [Supplementary materials are available for this article. Go to the publisher's online edition of American Journal of Bioethics for the following free supplemental resource(s): An additional table (Table 5) referred to on p. 5] [ABSTRACT FROM AUTHOR]

The article discusses the use of pain contracts or pain agreements, which are documents that are presented by a health care professional to a patient and describe the prescriber’s expectations of the patient and the conditions under which the physician will prescribe and/or discontinue opioids. In the article the authors offer opinions on the use of opioids to treat pain, on the use of pain contracts and on prescription drug abuse.

Much attention has been focused in recent years on the ethical acceptability of physicians receiving gifts from drug companies. Professional guidelines recognize industry gifts as a conflict of interest and establish thresholds prohibiting the exchange of large gifts while expressly allowing for the exchange of small gifts such as pens, note pads, and coffee. Considerable evidence from the social sciences suggests that gifts of negligible value can influence the behavior of the recipient in ways the recipient does not always realize. Policies and guidelines that rely on arbitrary value limits for gift-giving or receipt should be reevaluated. [ABSTRACT FROM AUTHOR]

Physician assistants (PAs), nurse practitioners (NPs), and medical residents constitute an increasingly significant part of the American health care workforce, yet patient assent to be seen by nonphysicians is only presumed and seldom sought. In order to assess the willingness of patients to receive medical care provided by nonphysicians, we administered provider preference surveys to a random sample of patients attending three emergency departments (EDs). Concurrently, a survey was sent to a random selection of ED residents and PAs. All respondents were to assume the role of patient when presented with hypothetical clinical scenarios and standardized provider definitions. Despite presumptions to the contrary, ED patients are generally unwilling to be seen by PAs, NPs, and residents. While seldom asked in practice, 79.5% of patients fully expect to see a physician regardless of acuity or potential for cost savings by seeing another provider. Patients are more willing to see residents than nonphysicians. [ABSTRACT FROM AUTHOR]

The article comments on a proposed autonomous framework for responding to knowledge about human cognitive biases. Issues and concerns tackled are biased thinking among people in making decisions, vulnerability of bioethicists to cognitive distortions in judgment, fiduciary responsibilities of medicine when a patient refuses medical treatment, and the Socratic approach of reliance on reasons and arguments when responding to biased views.

Physicians make some medical decisions without disclosure to their patients. Nondisclosure is possible because these are silent decisions to refrain from screening, diagnostic or therapeutic interventions. Nondisclosure is ethically permissible when the usual presumption that the patient should be involved in decisions is defeated by considerations of clinical utility or patient emotional and physical well-being. Some silent decisions - not all - are ethically justified by this standard. Justified silent decisions are typically dependent on the physician's professional judgment, experience and knowledge, and are not likely to be changed by patient preferences. We condemn the inappropriate exclusion of the patient from the decision-making process. However, if a test or treatment is unlikely to yield a net benefit, disclosure and discussion are at times unnecessary. Appropriate silent decisions are ethically justified by such considerations as patient benefit or economy of time. [ABSTRACT FROM AUTHOR]

This article argues that practitioners have a professional ethical obligation to dispense emergency contraception, even given conscientious objection to this treatment. This recent controversy affects all medical professionals, including physicians as well as pharmacists. This article begins by analyzing the option of referring the patient to another willing provider. Objecting professionals may conscientiously refuse because they consider emergency contraception to be equivalent to abortion or because they believe contraception itself is immoral. This article critically evaluates these reasons and concludes that they do not successfully support conscientious objection in this context. Contrary to the views of other thinkers, it is not possible to easily strike a respectful balance between the interests of objecting providers and patients in this case. As medical professionals, providers have an ethical duty to inform women of this option and provide emergency contraception when this treatment is requested. [ABSTRACT FROM AUTHOR]

The equipoise requirement in clinical research demands that, if patients are to be randomly assigned to one of two interventions in a clinical trial, there must be genuine doubt about which is better. This reflects the traditional view that physicians must never knowingly compromise the care of their patients, even for the sake of future patients. Equipoise has proven to be deeply problematic, especially in the Third World. Some recent critics have argued against equipoise on the grounds that clinical research is fundamentally distinct from clinical care, and thus should be governed by different norms. I argue against this “difference position,” and instead take issue with the traditional, exclusively patient-centered account of physicians' obligations that equipoise presupposes. In place of this traditional view, I propose a Kantian test for the reasonable partiality that physicians should show their patients, focusing on its application in clinical research and medical education. [ABSTRACT FROM AUTHOR]

Much attention has been given to determining whether an adolescent patient has the capacity to consent to research. This study explores the factors that influence adolescents' decisions to participate in a research study about youth violence and to determine positive or negative feelings elicited by being a research subject. The majority of subjects perceived their decision to participate to be free of coercion, and few felt badly about having participated. However, adolescents who were alone in the room during the assent process were more likely to report that they chose freely to be a research subject. This study may influence the ways physicians communicate with adolescent patients around research assent within a clinical care environment. [ABSTRACT FROM AUTHOR]

Expresses views on the operationalization of medical professionalism. Social factors that organized the status of medicine as a profession; Orientations toward professionalism established in the 1980s; Discussion on the issue of physician duty.

The threat of bioterrorism, the emergence of the SARS epidemic, and a recent focus on professionalism among physicians, present a timely opportunity for a review of, and renewed commitment to, physician obligations to care for patients during epidemics. The professional obligation to care for contagious patients is part of a larger "duty to treat," which historically became accepted when 1) a risk of nosocomial infection was perceived, 2) an organized professional body existed to promote the duty, and 3) the public came to rely on the duty. Physicians' responses to epidemics from the Hippocratic era to the present suggests an evolving acceptance of the professional duty to treat contagious patients, reaching a long-held peak between 1847 and the1950's. There has been some professional retrenchment against this duty to treat in the last 40 years but, we argue, conditions favoring acceptance of the duty are met today. A renewed embrace of physicians' duty to treat patients during epidemics, despite conditions of personal risk, might strengthen medicine's relationship with society, improve society's capacity to prepare for threats such as bioterrorism and new epidemics, and contribute to the development of a more robust and meaningful medical professionalism. [ABSTRACT FROM AUTHOR]

Malpractice insurance rates have created a crisis in American medicine. Rates are rising and reimbursements are not keeping pace. In response, physicians in the states hardest hit by this crisis are feeling compelled to take political action, and the current action of choice seems to be physician strikes. While the malpractice insurance crisis is acknowledged to be severe, does it justify the extreme action of a physician walkout? Should physicians engage in this type of collective action, and what are the costs to patients and the profession when such action is taken? I will offer three related arguments against physician strikes that constitute a prima facie prohibition against such action: first, strikes are intended to cause harm to patients; second, strikes are an affront to the physician-patient relationship; and, third, strikes risk decreasing the public's respect for the medical profession. As with any prima facie obligation, there are justifying conditions that may override the moral prohibition, but I will argue that the current malpractice crisis does not rise to the level of such a justifying condition. While the malpractice crisis demands and justifies a political response on the part of the nation's physicians, strikes and slow-downs are not an ethically justified means to the legitimate end of controlling insurance costs. [ABSTRACT FROM AUTHOR]

Much attention has been focused in recent years on the ethical acceptability of physicians receiving gifts from drug companies. Professional guidelines recognize industry gifts as a conflict of interest and establish thresholds prohibiting the exchange of large gifts while expressly allowing for the exchange of small gifts such as pens, note pads, and coffee. Considerable evidence from the social sciences suggests that gifts of negligible value can influence the behavior of the recipient in ways the recipient does not always realize. Policies and guidelines that rely on arbitrary value limits for gift-giving or receipt should be reevaluated. [ABSTRACT FROM AUTHOR]

The article examines the issue of professionally responsible clinical ethical judgments of futility in the Texas Advance Directives Act (TADA). Topics covered include how TADA is conservative in its trust and confidence in the professional integrity of physicians in making clinical judgments about what is medically inappropriate and of health care professionals who participate in the mandated review process by a medical or ethics committee.

[ABSTRACT FROM PUBLISHER]

The author discusses professionalism of physicians in the context of role morality when providing health care. He argues that moral significance of professionalism should be considered as function of role morality in solving the dual agency problem and its dangers in fostering professional actions. Also discussed are the professional responsibility and liability model, equality in the distribution of health care resources and structural injustice in access to health care.

The author reflects on Alex Kon's commentary on the case of Andrea, who was diagnosed with gender dysphoria. He presents several reasons to justify a physician's refusal to treat gender dysphoria. Also discussed are the ethical warrant of refusals involving physician's claim that the medications' risks are troubling, refusing to treat due to belief that it violates some aspect of moral integrity of the patient and moral repugnance.

The article discusses the article "Obstetricians and Violence Against Women" by Sonya Charles. In the article the authors offer their opinions on several points which are raised in Charles' article and on the moral and ethical issues that are raised when physicians and obstetricians discuss and offer opinions on health behavior with patients, and particularly, with pregnant women.

The article discusses the article "Obstetricians and Violence Against Women" by Sonya Charles. In the article the authors offer their opinions on several points which are raised in Charles' article, on alcohol use during pregnancy, on court ordered medical treatment for pregnant women and on the impact that gynecologists can have on the decision making process of women regarding health behavior.

A letter to the editor is presented in which Timothy D. Hotze, Kavita Shah, Emily Anderson and Matthew K. Wynia respond to criticisms about their article "Doctor, Would You Prescribe a Pill to Help Me . . . ? A National Survey of Physicians on Using Medicine for Human Enhancement.”

The article discusses the article "Clarifying Conflict of Interest," by Howard Brody. In the article the authors offer their opinions on several facts and assertions that are contained in Brody's article, on recommendations on conflicts of interest that were released by the U.S. Institute of Medicine and on how conflict of issue policies related to the field of medicine should be evaluated.

The article discusses the article "Doctor, Would you Prescribe a Pill to Help Me . . ?” A National Survey of Physicians on Using Medicine for Human Enhancement," by T. D. Hotze, K. Shah, E. E. Anderson and M. K. Wynia. In the article the authors offer their opinions on several assertions and facts found in Hotze's article, on ambivalence which has been voiced by physicians about the use of enhancement drugs and on the need for a new policy on the use of enhancement drugs which exists in the U.S.

Discusses the ethics training in graduate medical education. Perception of the residents on ethics training in residency; Importance of ethics training; Information on a physician charter published by leaders in internal medicine.

The article offers information on the conscientious objection to abortion in life-threatening medical emergency and the criminal liability of such actions in the U.S. Topics discussed include the criminal homicide conviction for such instances, the requirements for medical professionalism in the U.S., and the medical associations that support conscientious objections.

The author suggests the adoption of a Humean perspective to help physicians deal with brain death in the intensive care setting. Topics covered include the complications of the bioethics of brain death, an overview of the arguments in Book II of the "Treatise of Human Nature," by David Hume and the commonly cited difficulties with brain death that families do not understand.

In this article the author discusses the article "Precommitting to Serve the Underserved" by Nir Eyal and Till Bärnighausen, which is concerned with using conditional scholarships with medical students to increase the number of medical professionals in medically underserved areas across the globe. She is supportive of several points which are raised in Eyal and Bärnighausen's articles and of using conditional scholarships.

The article discusses the article "Obstetricians and Violence Against Women" by S. Charles. In the article the authors offer their opinions on several points which are raised in Charles' article, on ethical obstetrics care and on obstetric practices that may inadvertently contribute to the problem of violence against women.

The article discusses the article "Impairing Loyalty: Corporate Responsibility for Clinical Misadventure” by K. Kipnis, which focuses on the moral aspects that are associated with a physician's obligation to disclose information to a patient and the impact that influence from corporations can have on physicians. In the article the authors offer their opinions on Kipnis' article on the obligations that physicians have to disclose information to patients and on conflicts of interest in medicine.

In this article the author discusses aspects of the report "Is Continuous Sedation at the End of Life an Ethically Preferable Alternative to Physician-Assisted Suicide?," by K. Raus and colleagues. They note Raus and colleagues' argument that continuous deep sedation (CDS) can not substitute for physician-assisted suicide (PAS), explain why CDS is not ethically preferable to PAS, based on a distinction between pain and suffering, and discuss consciousness as a precondition for suffering.