Conflicts of interest are rampant in the American medical community. Today it is not uncommon for doctors to refer patients to clinics or labs in which they have a financial interest (40% of physicians in Florida invest in medical centers); for hospitals to offer incentives to physicians who refer patients (a practice that can lead to unnecessary hospitalization); or for drug companies to provide lucrative give-aways to entice doctors to use their "brand name" drugs (which are much more expensive than (...) generic drugs). In Medicine, Money and Morals, Marc A. Rodwin draws on his own experience as a health lawyer--and his research in health ethics, law, and policy--to reveal how financial conflicts of interest can and do negatively affect the quality of patient care. He shows that the problem has become worse over the last century and provides many actual examples of how doctors' decisions are influenced by financial considerations. We learn how two California physicians, for example, resumed referrals to Pasadena General Hospital only after the hospital started paying $70 per patient (their referrals grew from 14 in one month to 82 in the next). As Rodwin writes, incentives such as this can inhibit a doctor from taking action when a hospital fails to provide proper service, and may also lead to the unnecessary hospitalization of patients. We also learn of a Wyeth-Ayerst Labs promotion in which physicians who started patients on INDERAL (a drug for high blood pressure, angina, and migraines) received 1000 mileage points on American Airlines for each patient (studies show that promotions such as this have a direct effect on a doctor's choice of drug). Rodwin reveals why the medical community has failed to regulate conflicts of interest: peer review has little authority, state licensing boards are usually ignorant of abuses, and the AMA code of ethics has historically been recommended rather than required. He examines what can be learned from the way society has coped with the conflicts of interest of other professionals --lawyers, government officials, and businessmen--all of which are held to higher standards of accountability than doctors. And he recommends that efforts be made to prohibit and regulate certain kinds of activity (such as kickbacks and self-referrals), to monitor and regulate conduct, and to provide penalties for improper conduct. Our failure to face physicians' conflicts of interest has distorted the way medicine is practiced, compromised the loyalty of doctors to patients, and harmed society, the integrity of the medical profession, and patients. For those concerned with the quality of health care or medical ethics, Medicine, Money and Morals is a provocative look into the current health care crisis and a powerful prescription for change. (shrink)

Why do physicians have financial conflicts of interest? They arise because society expects physicians to act in their patients’ interest, while simultaneously, financial incentives encourage physicians to practice medicine in ways that promote their own interests or those of third parties. Because physicians’ clinical choices, referrals, and prescriptions affect the fortune of third parties, these third parties may offer physicians financial incentives to make income-driven clinical choices. In the past, physicians and scholars typically conceived of conflicts of interest as an (...) ethical issue to be resolved according to individual judgment or professional and organizational norms. However, society can mitigate or eliminate conflicts of interest by changing financial and organizational arrangements in medicine. Conflicts of interest, therefore, are as much matters of public policy and management as individual choices or social norms. (shrink)

The federal government indirectly subsidizes the pharmaceutical industry by funding basic research, various tax credits and deductions, patent rules, grants of market exclusivity, and other means, in order to spur drug development, promote public health, and improve medical care. But today, the pharmaceutical industry often neglects these goals and sometimes even undermines them, due to what Lawrence Lessig refers to as institutional corruption — that is, widespread or systemic practices, usually legal, that undermine an institution’s objectives or integrity. A key (...) source of institutional corruption is improper dependence by the institution or its key actors on the actions of third parties that have fundamentally different interests. It is the health care system’s improper dependency on pharmaceutical firms that allows them to displace some public policy goals and to compromise the attainment of others. (shrink)

Improper dependencies slant policy over a drug's life span, biasing the development of new drugs, the testing and marketing approval for new drugs, and the monitoring of patient safety after drugs are marketed. This article examines five ways in which the public improperly depends on pharmaceutical firms that compromise the integrity of pharmaceutical policy. Today the public relies on pharmaceutical firms: (1) to set priorities on drug research and development; (2) to conduct clinical trials to test whether drugs are safe (...) and effective; (3) to decide what clinical trial data to disclose to the public; (4) to monitor post marketing drug safety; (5) to supply product information to physicians and to finance continuing medical education and other professional activities. The article suggests options to overcome each of these dependencies. (shrink)

The Food and Drug Administration authorizes the marketing of a drug only for uses that the manufacturer has demonstrated to be safe and effective, based on evidence from at least two clinical trials. However, the FDA does not regulate the practice of medicine, so physicians may prescribe drugs in any manner they choose. Prescribing drugs in ways that deviate from the uses specified in the FDA-approved drug label, package insert, and marketing authorization is referred to as off-label prescribing. This occurs (...) when physicians prescribe a drug for a therapeutic purpose other than the one approved by the FDA; treat patients in a different age cohort or gender than the population on which it was tested; or prescribe a different dose, for a different duration of use, or a different mode of administration than indicated on the label. (shrink)

Through the 1960s, many people claimed that drug advertising was educational and physicians often relied on it. Continuing Medical Education (CME) was developed to provide an alternative. However, because CME relied on grants, industry funders chose the subjects offered. Now policymakers worry that drug firms support CME to promote sales and that commercial support biases prescribing and fosters inappropriate drug use. A historical review reveals parallel problems between advertising and industry-funded CME. To preclude industry influence and improve CME, we should (...) ensure independent funding by taxing medical industries, facilities and physicians. Independent public and professional authorities should create CME curricula. An independent agency should allocate all funds to educational institutions for approved curricula. (shrink)

Public policy tries to promote appropriate drug use by allowing firms to market drugs in interstate commerce only for uses that the Food and Drug Administration has found to be safe and effective. Because of their medical knowledge, physicians are authorized to prescribe drugs even for uses unapproved by the FDA. Nevertheless, physicians have relied on drug firms for information on appropriate prescribing despite the inherent tension between drug firm dissemination of information to promote sales and rational prescribing. In the (...) past, physicians often relied particularly on drug firm advertising for information on drug use. Today, physicians rely on drug firms to finance continuing medical education. A historical review reveals connections between these two different ways commercial interests have influenced the information that physicians receive and points the way to needed reforms. (shrink)

Prescribing drugs for uses that the FDA has not approved — off-label drug use — can sometimes be justified but is typically not supported by substantial evidence of effectiveness. At the root of inappropriate off-label drug use lie perverse incentives for pharmaceutical firms and flawed oversight of prescribing physicians. Typical reform proposals such as increased sanctions for manufacturers might reduce the incidence of unjustified off-label use, but they do not remove the source of the problem. Public policy should address the (...) cause and control the practice. To manage inappropriate off-label drug use, off-label prescriptions must be tracked in order to monitor the risks and benefits and the manufacturers’ conduct. Even more important, reimbursement rules should be changed so that manufacturers cannot profit from off-label sales. When off-label sales pass a critical threshold, manufacturers should also be required to pay for independent testing of the safety and effectiveness of off-label drug uses and for the FDA to review the evidence. Manufacturers should also finance, under FDA supervision, programs designed to warn physicians and the public about the risks of off-label drug use. (shrink)

The heart of the matter -- The evolution of the French medicine -- Coping with physicians' conflicts of interest in France -- The rise of a protected medical market : the United States before 1950 -- The commercial transformation : the United States, 1950-1980 -- The logic of medical markets : the United States, 1980 to the present -- Coping with physicians' conflicts of interest in the United States -- The evolution of Japanese medicine -- Coping with physicians' conflicts of (...) interest in Japan -- Reforms -- Professionalism reconsidered. (shrink)

This article compares the means that the United States, France, and Japan use to oversee pharmaceutical industry-physician financial relationships. These countries rely on professional and/or industry ethical codes, anti-kickback laws, and fair trade practice laws. They restrict kickbacks the most strictly, allow wide latitude on gifts, and generally permit drug firms to fund professional activities and associations. Consequently, to avoid legal liability, drug firms often replace kickbacks with gifts and grants. The paper concludes by proposing reforms that address problems that (...) persist when firms replace kickbacks with gifts and grants based on the experience of the three countries. (shrink)

Post-industrial societies confront common problems in pharmaceutical industry-physician relations. In order to promote sales, drug firms create financial relationships that influence physicians' prescriptions and sometimes even reward physicians for prescribing drugs. Three main types exist: kickbacks, gifts, and financial support for professional activities. The prevalence of these practices has evolved over time in response to changes in professional codes, law, and markets. There are certainly differences among these types of ties, but all of them can compromise physicians' independent judgment and (...) rational prescribing.Drug firms have paid kickbacks for prescribing drugs, purchasing drugs, switching brands prescribed, adding a drug to a hospital formulary, enrolling patients in post-marketing clinical trials, and writing practice guidelines that encourage the use of certain drugs. (shrink)

Is medical commerce a recent phenomenon? Does it distort the patient–physician relationship? Are investor-owned firms the main source of medical commercialism? I contend that medicine has generally been commerce in the United States, that medical commerce is a problem when it creates or worsens physicians' conflicts of interest, and that these conflicts thrive in nonprofit organizations as well as in investor-owned firms. I provide a historical sketch to show that physician entrepreneurialism, rather than commerce generally, is the main source of (...) physicians' conflicts of interest. (shrink)

The conventional wisdom is that managed care's brief life is over and we are now in a post-managed care era. In fact, managed care has a long history and continues to thrive. Writers also often assume that managed care is a fixed thing. They overlook that managed care has evolved and neglect to examine the role that it plays in the health system. Furthermore, private actors and the state have used managed care tools to promote diverse goals. These include the (...) following: increasing access to medical care; restricting physician entrepreneurialism; challenging professional control over the medical economy; curbing medical spending; managing medical practice and markets; furthering the growth of medical markets and private insurance; promoting for-profit medical facilities and insurers; earning bounties for reducing medical expenditures: and reducing governmental responsibility for, and oversight of, medical care. Struggles over these competing goals spurred the metamorphosis of managed care. This article explores how managed care transformed physicians' conflicts of interests and responses to them. It also examines how managed care altered the opportunities for patients/medical consumers to use exit and voice to spur change. (shrink)

Today, the goals of pharmaceutical policy and medical practice are often undermined due to institutional corruption — that is, widespread or systemic practices, usually legal, that undermine an institution's objectives or integrity. In this symposium, 16 articles investigate the corruption of pharmaceutical policy, each taking a different look at the sources of corruption, how it occurs, and what is corrupted. We will see that the pharmaceutical industry's own purposes are often undermined. Furthermore, pharmaceutical industry funding of election campaigns and lobbying (...) skews the legislative process that sets pharmaceutical policy. Moreover, certain practices have corrupted medical research, the production of medical knowledge, the practice of medicine, drug safety, the Food and Drug Administration's oversight of the pharmaceutical market, and the trustworthiness of patient advocacy organizations. (shrink)

Many writers suggest that managed care had a brief life and that we are now in a post-managed care era. Yet managed care has had a long history and continues to thrive. Writers also often assume that managed care is a fixed entity, or focus on its tools, rather than the context in which it operates and the functions it performs. They overlook that managed care has evolved and neglect to examine the role that it plays in the health system.This (...) article argues that private actors and the state have used managed care tools to promote diverse goals. These include the following: increasing access to medical care; restricting physician entrepreneurialism; challenging professional control over the medical economy; curbing medical spending; managing medical practice and markets; furthering the growth of medical markets and private insurance; promoting for-profit medical facilities and insurers; earning bounties for reducing medical expenditures; and reducing governmental responsibility for, and oversight of, medical care. Struggles over these competing goals spurred the metamorphosis of managed care internationally. (shrink)

George Berkeley, Bishop of Cloyne, was an Irish philosopher and divine who pursued a number of grand causes, contributing to the fields of economics, mathematics, political theory and theology. He pioneered the theory of 'immaterialism', and his work ranges over many philosophical issues that remain of interest today. This volume offers a complete and accurate edition of Berkeley's extant correspondence, including letters written both by him and to him, supplemented by extensive explanatory and critical notes. Alexander Pope famously said 'To (...) Berkeley every virtue under heaven', and a careful reading of the letters reveals a figure worthy of admiration, sheds new light on his personal and intellectual life, and provides insight into the broad historical and philosophical currents of his time. The volume will be an invaluable resource for philosophers, modern historians and those interested in Anglo-Irish culture. (shrink)

Donald Davidson's work has been of seminal importance in the development of analytic philosophy and his views on the nature of language, mind and action remain the starting point for many of the central debates in the analytic tradition. His ideas, however, are complex, often technical, and interconnected in ways that can make them difficult to understand. This introduction to Davidson's philosophy examines the full range of his writings to provide a clear succinct overview of his ideas. This book begins (...) with an account of the assumptions and structure of Davidson's philosophy of language, introducing his compositionalism, extensionalism and commitment to a Tarski-style theory of truth as the model for theories of meaning. It goes on to show how that philosophical framework is to be applied and how it challenges the traditional picture. Marc Joseph examines Davidson's influential work on action theory and events and discusses the commonly made charge that his theory of action and mind leaves the mental as a mere 'epiphenomenon' of the physical. The final section explores Davidson's philosophy of mind, some of its consequences for traditional views of subjectivity and objectivity and, more generally, the relation between minded beings and the physical and mental world they occupy. (shrink)

"A wide-ranging study of the 'way of ideas' and its metaphysics, culminating in a bold reinterpretation of Berkeley.".

The prevailing view about the history of early modern philosophy, which the author dubs “the early modern tale” and wants to convince us is really a fairy tale, has it that the focus on ideas as a solution to various epistemological puzzles, first introduced by Descartes, created difficulties for the traditional ontological scheme of substance and mode. The early modern tale depicts the development of “the way of ideas” as abandoning ontology at least by the time of Berkeley. This, in (...) turn, fostered an antimetaphysical bias as modern philosophy developed further, elevating epistemology to its current primary status in the field. Marc Hight challenges this account by showing how, though the conception of ideas changed over time, the ontological status of ideas remained a central part of the discussion about ideas and influenced how even later thinkers like Locke, Berkeley, and Hume thought about them. By his reading of important texts in early modern philosophy, Hight aims not only to provide a more accurate history of philosophy for this period but also to resuscitate the value of metaphysics for philosophical analysis today.��. (shrink)

Joseph Heath defends competitive markets and conceptualizes business ethics with reference to Pareto efficiency, which he takes to be the “implicit morality of the market.” His justification for markets is that they generate Pareto efficient outcomes, meaning that markets optimally satisfy consumer preferences. And, for Heath, business ethics is the set of normative constraints—regulation and beyond-compliance norms—needed to preserve that outcome. The present paper accepts Heath’s claim that the economic justification for markets is ethical, in that satisfying consumer preferences is (...) a good. But, contra Heath, the ethical consideration at work is a consequentialist one; and acknowledging this consequentialism exposes limitations of Heath’s “market failures” approach to business ethics. We suggest two limitations, and we expect many will accept our argument that Heath’s conception of business ethics is too narrow. The present paper outlines two broader implications. First, acknowledging that the justification for markets is ethical eliminates the apparent—and false—conflict between purportedly amoral economic activity on one hand and ethical considerations on the other; instead, business ethics is a matter of weighing the consequentialist ethical benefit of economic activity and markets against other moral arguments/other ethical considerations. Second, Heath restricts business ethics to the constraints needed to protect the market’s ability to efficiently satisfy consumer preferences, constraints he calls “efficiency imperatives”; this restriction supports the widespread tendency to think that all social problems are economic; and, a business ethics so-conceived diminishes the perceived importance of noneconomic values—this attitude is dangerous. (shrink)

The American Journal of Bioethics, Volume 11, Issue 10, Page 36-37, October 2011.

This paper argues that Rawls’ principles of justice provide a normative foundation for stakeholder theory. The principles articulate (at an abstract level) citizens’ rights; these rights create interests across all aspects of society, including in the space of economic activity; and therefore, stakeholders – as citizens – have legitimate interests in the space of economic activity. This approach to stakeholder theory suggests a political interpretation of Boatright’s Moral Market approach, one that emphasizes the rights/place of citizens. And this approach to (...) stakeholder theory – in terms of citizens – raises a further question, what rights and obligations do economic agents have, beyond those attached to their roles as citizens? Rawls would reject additional rights and obligations of this sort for two reasons, one tied to freedom and one tied to pluralism. Rawls’ work therefore presses us to re-conceptualize the place of ethical claims in the economic context. (shrink)

The singular term theory maintains that that-clauses are complex singular terms which designate propositions. Though extremely well-supported, the theory is endangered by the existence of oblique that-clauses; that is, that-clauses occurring in what appear to be nonargument positions (e.g., ‘Lola was upset that Slick Willy had all the fun’). In this paper I argue that the best solution to the problem consistent with the singular term theory, invokes a construction-based grammatical theory. Such an approach challenges traditional views of semantic compositionality (...) by rejecting a central dogma of semantics, namely, that linguistic constructions contribute only trivial logical or quasi-logical information to semantic interpretation (e.g., function-application relations). (shrink)

Bernard Williams briefly discusses agent regret in his broader account of moral luck. The present paper first outlines one way to develop Williams’s notion with reference to the unintended harm; it then suggests that agent regret can be counteracted by externalizing the action that caused unintended harm, in Harry Frankfurt’s sense of externalization; and then the present paper argues that apology is a mechanism by which a person can externalize an offending action/effect—in that way counteracting agent regret. This function for (...) apology—self-repair—is different from others described in the literature, which address the role of apology in repairing relationships. The present paper describes a nonfictional example, that of a veteran of the U.S. war in Iraq who contacts a family gravely injured by him and his combat unit; the veteran is motivated to contact the family to apologize. The example serves as a prototypical case of agent regret. The example is taken from a recent literature on the clinical psychology of self-inflicted “moral injury”; categorizing this example of moral injury as agent regret also helps broaden our understanding of moral injury as a philosophical category and as a psychological phenomenon. (shrink)

Across the management, social science, and business ethics literatures, and in much of the philosophy literature, trust is characterized as a disposition to act given epistemic states—beliefs and/or expectations about others and about the risks involved. This characterization of trust is best thought of as epistemological because epistemic states distinguish trust from other dispositions. The epistemological characterization of trust is the amoral one referred to in the title of this paper, and we argue that this characterization is conceptually inadequate. We (...) outline and defend an alternative conception of trust as a moral phenomenon: when A trusts B to do something, A invites B to acknowledge and accept an obligation; when B accepts the invitation, B takes on an obligation; in that way trust creates an obligation. We conclude with an application, drawing out the difference between the epistemological conception of trust and our own in the context of Ghoshal et al.'s (Sloan Management Review 40:9—20, 1995, Academy of Management Learning & Education 4:75—91, 2005) critique of transaction cost theories of the firm. (shrink)

This book explores convergences and divergences between process thought and Roman Catholicism. It examines why process philosophy and process theology have had a minimal impact in Roman Catholic circles compared to Protestantism, and investigates avenues of promising engagement between process thought and Roman Catholicism.

Book Review of "The Purposes of God: Providence as Process-Historical Liberation" by G. Michael Zbaraschuk.

The Problem of Doxastic Shift may be stated as a dilemma: on the one hand, the distribution of nominal complements of the form `the ψ that p’ strongly suggests that `that’-clauses cannot be univocally assigned propositionaldenotations; on the other hand, facts about quantification strongly suggest that `that’-clauses must be assigned univocal denotations. I argue that the Problem may be solved by defining the extension of a proposition to be a set of facts or, more generally, conditions. Given this, the logical (...) operation of descriptive predication can be introduced in a way that resolves the dilemma withoutsacrificing the singular term analysis of `that’-clauses. (shrink)

Bryan Norton proposes a "convergence hypothesis'* stating that anthropocentrists and nonanthropocentrists can arrive at common environmental policy goals if certain constraints are applied. Within his theory he does not, however, address the consideration ofnonconsequentualist issues, and, therefore, does not provide an argument for the convergence between consequentualist and nonconsequentualist ethical positions. In the case of biotechnology, nonconsequentualist issues can dominate the debate in both the fields of environmental ethics and bioethics. I argue that, the convergence hypothesis must be rejected when (...) tested against the case of biotechnology, and this limitation of convergence applies to any theory of reconciliation within the "health" concept because the achievement and preservation of "health "emphasizes a consequentualist outlook. I conclude that an inclusive ethics for ecosystem and human health should be explicit about this limitation. (shrink)

Experiential evidence shows that pain is associated with common meanings. These include a meaning of threat or danger, which is experienced as immediately distressing or unpleasant; cognitive meanings, which are focused on the long-term consequences of having chronic pain; and existential meanings such as hopelessness, which are more about the person with chronic pain than the pain itself. This interdisciplinary book - the second in the three-volume Meanings of Pain series edited by Dr Simon van Rysewyk - aims to better (...) understand pain by describing experiences of pain and the meanings these experiences hold for the people living through them. The lived experiences of pain described here involve various types of chronic pain, including spinal pain, labour pain, rheumatic pain, diabetic peripheral neuropathic pain, fibromyalgia, complex regional pain syndrome, endometriosis-associated pain, and cancer-related pain. Two chapters provide narrative descriptions of pain, recounted and interpreted by people with pain. Language is important to understanding the meaning of pain since it is the primary tool human beings use to manipulate meaning. As discussed in the book, linguistic meaning may hold clues to understanding some pain-related experiences, including the stigmatisation of people with pain, the dynamics of patient-clinician communication, and other issues, such as relationships between pain, public policy and the law, and attempts to develop a taxonomy of pain that is meaningful for patients. Clinical implications are described in each chapter. This book is intended for people with pain, their family members or caregivers, clinicians, researchers, advocates, and policy makers. (shrink)

: Establishing and defending the Christian faith serves as both a guide and a limit to Berkeley's intriguing metaphysics. I take Berkeley seriously when he says that his aim is to promote the consideration of God and the truth of Christianity. In this paper I discuss and engage Berkeley's superficially weak argument (which I call the natural analogy argument) in defense of the plausibility of the doctrine of bodily resurrection. When his immaterialist resources are properly applied, the argument has more (...) merit than one might initially believe. I conclude by speculating that Berkeley had reason to believe that immaterialism was a better fit with Christianity than materialism. (shrink)

There are two constraints on any functionalist solution to the Mind-Body Problem construed as an answer to the question, “What is the relationship between the mental properties and relations (hereafter, simply the mental properties) and physical properties and relations?” The first constraint is that it must actually address the Mind-Body Problem and not simply redefine the debate in terms of other, more tractable, properties (e.g., the species-specific property of having human-pain). Such moves can be seen to be spurious by the (...) very multiple-realizability intuitions that motivate functionalism in the first place. For, according to those intuitions, it is possible for a being to experience pain, have beliefs, etcetera, and yet not only to be of a different species, but to have an entirely different material constitution from human beings. (shrink)

In this article we argue that an immaterialist ontology -- a metaphysic that denies the existence of material substance -- is more consonant with Christian dogma than any ontology that includes the existence of material substance. We use the philosophy of the famous eighteenth-century Irish immaterialist George Berkeley as a guide while engaging one particularly difficult Christian mystery: the doctrine of the Incarnation of Christ. The goal is to make plausible the claim that, from the analysis of this one example, (...) there are strong reasons for thinking that if one wants to be a Christian one ought to be an immaterialist. (shrink)

The most recent restatements of stakeholder theory formulate that approach in terms of the distribution of value: “A stakeholder approach to business is about creating as much value as possible for stakeholders, without resorting to tradeoffs” (Freeman et al. 2010: 28). This formulation marks a shift from earlier work, which included a procedural dimension—a requirement that stakeholders participate in organization decision making. The present paper pushes back against this shift: it argues that orienting the stakeholder approach around the participation requirement (...) provides for a different moral logic, one not available to (now) conventional stakeholder theorizing (without that requirement), and one that may be more compelling to many. This argument requires critical re-examination of the moral arguments offered in the most recent restatements of the stakeholder approach. (shrink)

Ludwig Wittgenstein’s _Tractatus Logico-Philosophicus_ is among the most ambitious and influential philosophical works of the early twentieth century, and in recent years it has again occupied a central position in discussions of Wittgenstein’s philosophy. Written in an austere and meticulous style, the _Tractatus_ addresses questions in the philosophy of language, logic, and metaphysics, and, according to its author, provides a solution to all the problems of philosophy. This Broadview Edition contains the original English translation by C.K. Ogden and Frank P. (...) Ramsey, annotated and revised by the editor for improved accuracy and clarity. Appendices include important material by Gottlob Frege and Bertrand Russell, as well as excerpts from Wittgenstein’s other writings. (shrink)