Search

In theory, physicians subscribe to and in their actions personify a set of virtues whose performance demands personal engagement. At the same time, they are instructed in their professional roles to remain emotionally and personally distant from those they are called to treat. The result, the authors argue, is an ethical conflict whose nature is described through an analysis of two narratives drawn from an online blog for young physicians. Confusion over professional responsibilities and personal roles were found to affect physicians' perceptions of their clinical duties and their social roles. In addition, it sets in sharp relief contemporary debates on physician training and the ethical nature of medical professionalism. Practically, the authors suggest, the confusion may contribute to early physician burnout. Methodologically, this paper promotes the use of online discussion sites as rich repositories providing an insight into real dilemmas and the actual perception of physicians' attempts to address them. It thus promotes use of such sites as a resource in which assumptions about physicians' own perceptions about the nature of their role in contemporary society can be tested. doi: 10.1136/jme.2009.034900

Background: The American Medical Association, the British Medical Association and the Canadian Medical Association have guidelines that specifically discourage physicians from self-prescribing or prescribing to family members, but only the BMA addresses informal prescription requests between colleagues. Objective: To examine the practices of paediatric providers regarding self-prescribing, curbsiding colleagues, and prescribing and refusing to prescribe to friends and family. Methods: 1086 paediatricians listed from the American Academy of Paediatrics 2007 web-based directory were surveyed. Results: 44% (430/982) of eligible survey respondents returned usable surveys. Almost half (198/407) of respondents had prescribed for themselves. An equal number (198/411) had informally requested a prescription from a colleague. Three-quarters (325/429) stated they had been asked to prescribe a prescription drug for a first-degree or second-degree relative, and 51% (186/363) had been asked by their spouse. Eighty-six per cent (343/397) stated that they had refused to write a prescription on at least one occasion for a friend or family member. The following reasons 'strongly influenced' their decision to refuse a prescription request: (1) outside of provider's expertise (88%); (2) patient's need for his or her own physician (70%); (3) not medically indicated (69%); (4) need for a physical examination (65%). Conclusion: These data confirm that most physicians have engaged in self-prescribing or curbside requests for prescriptions. It can be argued that curbsiding is more morally problematic than self-prescribing because it implicates a third party, and should be discouraged regardless of whether the requester is a colleague, family member or friend. doi: 10.1136/jme.2009.032169

Objective: To evaluate whether ethics rounds stimulated ethical reflection. Methods: Philosopher-ethicist-led interprofessional team ethics rounds concerning dialysis patient care problems were applied at three Swedish hospitals. The philosophers were instructed to stimulate ethical reflection and promote mutual understanding between professions but not to offer solutions. Questionnaires directly before and after rounds were answered by 194 respondents. The analyses were primarily content analysis with Boyd's framework but were also statistical in nature. Findings: Seventy-six per cent of the respondents reported a moderate to high rating regarding new insights on ethical problem identification, but the ethics rounds did not seem to stimulate the ethical reflection that the respondents had expected (p Conclusion: The findings show the need for interprofessional reflective ethical practice but a balance between ethical reflection and problem solving is suggested if known patients are discussed. Further research is needed to explore the most effective leadership for reflective ethical practice.

Objectives: The aim of this study is to evaluate the views of cancer patients on patient rights in the context of the right to information and autonomy according to articles related to the issue in the 'Patient Rights Regulation'. Methods: The research was conducted among cancer patients in the medical oncology department of a research and practice hospital using a random sampling method between June and September 2005. Data were collected during face-to-face interviews using a questionnaire. Results: There was a high rate of positive response to the items that the patients have the right to be informed (86.5%), that the physician should inform the patient on the diagnosis and the treatment (92.3%) and that the physician is obliged to inform the patient (76.9%). Only 43.3% of the patients stated that the patient has the right to refuse the treatment recommended by the physician. The participants mostly agreed that the patient should participate in decisions about the treatment and that patient consent should be given (78.8%). Conclusions: There are extensive efforts in Turkey towards making patient rights a significant supportive component of health services. For patient rights to become a natural part of medical practice it is necessary to give priority to education of both patients and physicians about patient rights and to lay emphasis on an ethical approach in the patient--physician relationship.

When may a physician enroll a patient in clinical research? An adequate answer to this question requires clarification of trust-based obligations of the state and the physician-researcher respectively to the patient-subject. The state relies on the voluntarism of patient-subjects to advance the public interest in science. Accordingly, it is obligated to protect the agent-neutral interests of patient-subjects through promulgating standards that secure these interests. Component analysis is the only comprehensive and systematic specification of regulatory standards for benefit-harm evaluation by research ethics committees (RECs). Clinical equipoise, a standard in component analysis, ensures the treatment arms of a randomised control trial are consistent with competent medical care. It thus serves to protect agent-neutral welfare interests of the patient-subject. But REC review occurs prior to enrolment, highlighting the independent responsibility of the physician-researcher to protect the agent-relative welfare interests of the patient-subject. In a novel interpretation of the duty of care, we argue for a 'clinical judgment principle' which requires the physician-researcher to exercise judgment in the interests of the patient-subject taking into account evidence on treatments and the patient-subject's circumstances. doi: 10.1136/jme.2005.014670

Objective: To examine students' attitudes and potential behaviour towards informing a 12-year-old patient of her terminal prognosis in a situation in which her parents do not wish her to be told, as they pass through a modern medical curriculum. Design: A cohort study of students entering Glasgow University's new medical curriculum in October 1996. Methods: Students' responses obtained before year 1 and at the end of years 1, 3, and 5 to the 'childhood leukaemia' vignette of the Ethics in Health Care Survey Instrument (EHCI) were examined quantitatively and qualitatively. Analysis of the students' multichoice answers enabled measurement of the movement towards professional consensus opinion. An analysis of their written justifications for their answers helped to determine whether their reasoning was consistent with professional consensus and enabled measurement of changes in knowledge content and recognition of the values inherent in the vignette. Themes on the students' reasoning behind their decision to tell the patient or not were also identified. Results: Unlike other vignettes of the EHCI in which autonomy was a main theme, few students chose the consensus answer before year 1 and there was no significant movement towards consensus at any point during the course. In defence of their decision to withhold information, the students expressed strong paternalistic opinions. The patient's age was seen as a barrier to respecting her autonomy. Conclusions: It is important to identify students perceptions on entry to medical school. Transformative learning theory may provide the basis for an approach to foster doctors who consider the rights of young people. Small-group teaching is most conducive to this approach. The importance of positive role modelling is also emphasised.

Following the influential Gifford and Reith lectures by Onora O'Neill, this paper explores further the paradigm of individual autonomy which has been so dominant in bioethics until recently and concurs that it is an aberrant application and that conceptions of individual autonomy cannot provide a sufficient and convincing starting point for ethics within medical practice. We suggest that revision of the operational definition of patient autonomy is required for the twenty first century. We follow O'Neill in recommending a principled version of patient autonomy, which for us involves the provision of sufficient and understandable information and space for patients, who have the capacity to make a settled choice about medical interventions on themselves, to do so responsibly in a manner considerate to others. We test it against the patient-doctor relationship in which each fully respects the autonomy of the other based on an unspoken covenant and bilateral trust between the doctor and patient. Indeed we consider that the dominance of the individual autonomy paradigm harmed that relationship. Although it seems to eliminate any residue of medical paternalism we suggest that it has tended to replace it with an equally (or possibly even more) unacceptable bioethical paternalism. In addition it may, for example, lead some doctors to consider mistakenly that unthinking acquiescence to a requested intervention against their clinical judgement is honouring 'patient autonomy' when it is, in fact, abrogation of their duty as doctors.

The medical ethics of a physician's relationship with a prisoner who is participating in a collective hunger strike has become a major public, professional, and governmental concern in The Republic of Turkey. This article examines the Turkish experience and debate about physician ethics during prison hunger strikes. It is hoped that this analysis will be of use to those formulating policy in similar situations.

Objective: To gain insight into the standards of rationality that physicians use when evaluating patients' treatment refusals. Design of the study: Qualitative design with indepth interviews. Participants: The study sample included 30 patients with cancer and 16 physicians (oncologists and general practitioners). All patients had refused a recommended oncological treatment. Results: Patients base their treatment refusals mainly on personal values and/or experience. Physicians mainly emphasise the medical perspective when evaluating patients' treatment refusals. From a medical perspective, a patient's treatment refusal based on personal values and experience is generally evaluated as irrational and difficult to accept, especially when it concerns a curative treatment. Physicians have a different attitude towards non-curative treatments and have less difficulty accepting a patient's refusal of these treatments. Thus, an important factor in the physician's evaluation of a treatment refusal is whether the treatment refused is curative or non-curative. Conclusion: Physicians mainly use goal oriented and patients mainly value oriented rationality, but in the case of non-curative treatment refusal, physicians give more emphasis to value oriented rationality. A consensus between the value oriented approaches of patient and physician may then emerge, leading to the patient's decision being understood and accepted by the physician. The physician's acceptance is crucial to his or her attitude towards the patient. It contributes to the patient's feeling free to decide, and being understood and respected, and thus to a better physician-patient relationship.

Context: A growing number of Japanese people have completed advance directives, especially living wills, even though there is no legislation recognising such documents and little empirical research on their impact on clinical care at the end of life in Japan. Objectives: To investigate physicians' attitudes about living wills and their experiences with patients who had completed a living will and later died. Design: Self administered survey and qualitative study using open question and content analysis. Setting: Japan. Participants: Physicians known to have cared for a patient who had presented a living will prior to death. Measurements: The physician's response to receiving a living will, communication about the living will, the impact of the living will on clinical care, demographics, and their opinion on advance directives, especially living wills. Main results: Fifty five per cent of respondents approved of advance directives in general, and 34% had more opportunities to communicate with a patient and his/her family after receiving the living will. Sixty nine per cent of the physicians who received a living will did not, however, change their course of therapy as a consequence of receiving the living wills. Based on the analysis, we identified three areas of concern in the comments on living wills: (1) concerns relative to patients, physicians, and families; (2) social context, and (3) clinical and administrative concerns. The physicians raised various topics for discussion; they tended to describe the issues from a clinical perspective. Conclusions: Our identified areas of concern should prove helpful in better understanding the clinical and ethical implications of living wills in Japan., In recent decades, Japan has witnessed growing interest in the expression and enhancement of individual autonomy in medical decision making at the end of life. (1 2) Written advance directives [...]

In the light of increasing public mistrust, there is an urgent need to clarify the moral status of the medical profession and of the relationship of the clinician to his/her patients. In addressing this question, I first establish the coherence, within moral philosophy generally, of the concept of supererogation (the doing of more than one's duty). I adopt the notion of an act of 'unqualified' supererogation as one that is non-derivatively good, praiseworthy, and freely undertaken for others' benefit at the risk of some cost to the agent. I then argue that committing oneself to the profession of clinical medicine is an act of this kind. This is the case, not because the aim of medicine is to help patients, but because of the open ended commitment of time and the vulnerability to the consequences of failure that the clinician must accept., The recent outbreak of public criticism of the medical profession in the UK over retention of organs after autopsy without consent is only the latest in a series of cases [...]

Background - Patient autonomy has gradually replaced physician paternalism as an ethical ideal. However, in a medical context, the principle of individual autonomy has different meanings. More knowledge is needed about what is and should be an appropriate understanding of the concept of patient autonomy in clinical practice. Aim - To challenge the traditional concept of patient autonomy by applying a discourse analysis to the issue. Method - A qualitative case study approach with material from one consultation. The discourse is interpreted according to pragmatic and text-linguistic principles and provides the basis of a theoretical discussion of different concepts of patient autonomy. Results - The consultation transcript illustrates how the patient's wishes can be respected in real life. The patient, her husband and the doctor are all involved in the discourse dynamics, governed by the subject matter, namely her mental illness. Conclusion - We suggest a dynamic and dialogue-based conception of autonomy as adequate for clinical purposes. These perspectives, based on mutual understanding, take communication between patient and doctor as their starting point. According to this approach, autonomy requires a genuine dialogue, an interpersonal mode of being which we choose to call 'authentic interaction'. Keywords: Patient-doctor encounter; discourse analysis; patient autonomy; vital lies; authenticity

This paper addresses ethical concerns emanating from the practice of using patients for health care education. It shows how some of the ways that patients are used in educational strategies to bridge theory-practice gaps can cause harm to patients and patient-practitioner relationships, thus failing to meet acceptable standards of professional practice. This will continue unless there is increased awareness of the need for protection of human rights in teaching situations. Unnecessary exposure of patients, failing to obtain explicit consent, causing harm to vulnerable or disadvantaged groups and inappropriate use of information, though normally regarded as unacceptable professional practices, may go unrecognised in meeting educational needs, widening rather than narrowing theory-practice gaps. Keywords: Health care education; theory-practice gap; professional accountability; human rights; codes of professional conduct

'Best interests 'is widely accepted as the appropriate foundation principle for medico-legal decisions concerning treatment withdrawal from patients in persistent vegetative state (PVS). Its application appears to progress logically from earlier use regarding legally incompetent patients. This author argues, however, that such confidence in the relevance of the principle of best interests to PVS is misplaced, and that current construction in this context is questionable on four specific grounds. Furthermore, it is argued that the resulting legal inconsistency is distorting both the principle itself and, more particularly, individual patient interests. Keywords: Persistent vegetative state; 'best interest'; legal decisions

New methods must be evolved to improve values education in medical studies and resources should be channelized in this direction. The use of a values journal, which is based on students' personal life experiences and their decisions is suggested. Such a method not only enhances students' capability to make decisions, but also provides the needed guidance so that they can encourage patients to develop their own value systems.

Daniel Callahan has argued that economic and social benefits would result from a policy of withholding medical treatments which prolong life in persons over a certain age. He claims 'the real goal of medicine' is to conquer death and prolong life with the use of technology, regardless of the age and quality of life of the patient, and this has been responsible for the escalation of health care expenditure. Callahan's proposal is based on economic rationalism but there is little evidence to suggest that substantial economic savings could be achieved. Moreover, his argument raises serious moral objections. A policy of withholding treatments from members of a social group involves elements of compulsion and discrimination, both of which would intrude on the doctor-patient relationship, undermine the autonomy of elderly patients, and invoke the slippery slope towards involuntary forms of euthanasia. Life-death decisions should be based on more than the one criterion of age, and take account of more relevant factors such as the patient's usual state of well-being, her/his expressed wishes, informed consent and the type of illness. Any move to the implementation and enforcement of the policy Callahan recommends would be rejected by health professionals and the public.

A response to a critique by Roger W Hunt of my views on the eventual likely need to use age as a standard for the allocation of expensive, high-technology, life-extending medical care for the elderly. The response encompasses three elements: 1. that while the elderly have a substantial claim to publicly-provided health care, it cannot be an unlimited claim; 2. that a health care system which provided a decent, coherent set of medical and social services for the elderly would be sufficient, even if some limits had to be set; and 3. allocation and rationing decisions should not be made by individual doctors at the bedside but by regional or national policy.

Contrary to the usual discussion of lying or deceiving in medical ethics literature where the lying or deceiving is done by the doctor or surgeon, this paper deals with lying or deceiving on the part of the patient. Three cases involving HIV-infected male homosexual or bisexual persons are presented. In each case the patient deceives or wants the doctor to deceive a third party on his behalf. Are such deceptions or lies expressions of compassion? Are they in the patient's best interests? Do they compromise the doctor's integrity? It is submitted that societal attitudes towards male homosexual acts were internalised by the men described in these cases. Thus, a dichotomy was created between the private life and the public image. Fear of condemnation by the doctor or others restricted communication towards the goal of the maintenance of the patient's health. The lack of trust which inhibits truth-telling results in mutual and progressive isolation and impedes the provision of optimal care.

During medical training students and residents reconstruct their view of the world. Patients become bodies; both the faults and the virtues of the medical profession become exaggerated. This reconstruction has moral relevance: it is in part a moral blindness. The pain of medical training, together with its narrowness, contributes substantially to these faulty reconstructions. Possible improvements include teaching more social science, selecting chief residents and faculty for their attitudes, helping students acquire communication skills, and helping them deal with their own pain. Most importantly, clearer moral vision requires time and scope for reflection.

This paper concerns the difficulties of imagining the subjective point of view of another human being, and the relevance of these difficulties to medical decisions. It explores especially the difficulties of imagining the experience of the mentally impaired, and examines several standards for decision-making: the |prior expressed wishes standard', the |substituted judgement standard', and the |best interests standard'.

Are doctors and nurses bound by just the same constraints as everyone else in regard to honesty? What, anyway, does honesty require? Telling no lies? Avoiding intentional deception by whatever means? From a utilitarian standpoint lying would seem to be on the same footing as other forms of intentional deception: yielding the same consequences. But utilitarianism fails to explain the wrongness of lying. Doctors and nurses, like everyone else, have a prima facie duty not to lie - but again like everyone else, they are not duty-bound to avoid intentional deception, lying apart; except where it would involve a breach of trust.

Technological development and the desire for better management require information from the patients but ignores the importance of confidentiality in a doctor-patient relationship. The reforms in the National Health Services (NHS) will make confidentiality impossible, forcing patients to withhold essential information from the doctor. Better health care delivery necessitates the disposal of NHS and other such information trading agencies.

It is now widely accepted that a patient's ability to engage in autonomous decision-making can be seriously threatened when she denies significant aspects of her medical condition. In this paper I use a true case to reveal the harmful effects of physician denial upon patient autonomy and well-being. I suggest further that such physician denial may be more common than is generally acknowledged, since aspects of the contemporary medical ethos likely serve to reinforce rather than to undercut such denial.

This paper addresses ethical concerns emanating from the practice of using patients for health care education. It shows how some of the ways that patients are used in educational strategies to bridge theory-practice gaps can cause harm to patients and patient-practitioner relationships, thus failing to meet acceptable standards of professional practice. This will continue unless there is increased awareness of the need for protection of human rights in teaching situations. Unnecessary exposure of patients, failing to obtain explicit consent, causing harm to vulnerable or disadvantaged groups and inappropriate use of information, though normally regarded as unacceptable professional practices, may go unrecognised in meeting educational needs, widening rather than narrowing theory-practice gaps. Keywords: Health care education; theory-practice gap; professional accountability; human rights; codes of professional conduct

Introduction: Consultation methods differ between medical practitioners depending on the individual setting. However, the central tenet to the doctor-patient relationship is the issue of confidentiality. This prospective survey highlights patient attitudes towards consultation methods in the setting of an ophthalmic outpatient department. Method: Questionnaires were completed by 100 consecutive patients, who had been seen by an ophthalmologist in a single room, which had a joint doctor-patient consultation occurring simultaneously. Results: Each question of all 100 questionnaires was completed. 58% of patients were not concerned about sharing a consultation room with another patient or doctor. However, this did not equate to the 49% of patients who were indifferent to discussing issues in the joint consultation room. The most common factor was the general issue of confidentiality. Discussion: Ensuring total patient confidentiality may be deemed more necessary far certain medical specialties than far others, as seen in the practice of separate medical records in genitourinary medicine, for instance. However, with regard to patient consultations, the same level of confidentiality should be afforded across all specialties, and such factors should be borne in mind when planning outpatient clinics.

Withdrawal of active treatment is common in medical practice, especially in critical care medicine. Usually, however, it involves patients who are unable to take part in the decision making process. As the case of Ms B shows, doctors are sometimes reluctant to withdraw active treatment when the patient is awake and requesting such a course of action. In theory, having a competent patient should facilitate clinical decision making, so where does the problem arise? It is argued that latent medical paternalism may come to the surface when doctors are asked by patients to follow a course of action which is in conflict with their own perspective., In recent years medical paternalism has given way to patient autonomy. This does not mean that patients can dictate to doctors, but it does mean that patients should be treated [...]

Ethical problems confronting public health practitioners have, relatively speaking, received scant attention. No doubt this is in part due to the traditional emphasis in medical ethics on the dynamics of [...]

The establishment of clinical ethics committees (CECs) would guarantee the implementation of ethical guidelines and, hence, facilitate its practice among hospital staff. CECs also reduce the incidence of lawsuits by helping to diffuse conflicts among staff members and between physicians and patients. Critics, however, argue that CECs would diminish the autonomy of doctors and restrict the patient's freedom of choice.

A view from a student: ethical teaching, based on ethical guidelines, is at odds with clinical practice. Is this poor practice, or is the ethical guidance too simple?