Technological advances in the field of medicine and health sciences not only manipulate the normal human body and sex but also provide for surgical and hormonal management of hermaphroditism. Consequently, sex assignment surgery has not only become a standard care for babies born with genital abnormalities in the West but even in some Muslim states. On the positive side, it goes a long way in saving children born with abnormal genitalia from numerous legal interdictions of the pre-sex corrective surgery. (...) Nevertheless, the larger ethical and legal questions that medical management of genital abnormality raises to some extent have not been adequately appreciated by contemporary Muslim responses. This article, therefore, in principle argues against surgical management of intersexuality during early infancy from the Islamic legal perspective. (shrink)

The effectiveness of a quality management program of medical care has to meet not just the quality management standards, but also has to be flexible, taking into account the features of a medical organization and the existing problems in the medical care support. The effectiveness of a quality management program is based on feedback, so the quality control of medical care is so important. The study of problems in medical care gives us (...) the ability to improve both, the quality management program of medical care and the quality and scope of medical services constantly. (shrink)

Managed care is evolving in ways that pose unique ethical challenges to those interested in the intersection of clinical and organizational ethics. For example, Disease Management is a form of managed care that has emerged in response to chronic illness. DM is a healthcare management tool that coordinates resources across an entire health care delivery system and throughout the life cycle of chronic disease. Health Maintenance Organizations have reduced some costs in the delivery of acute care, but real (...) cost savings will result only with greater efficiencies in the delivery of costly chronic care. DM is a systematic, population-based approach that identifies persons at risk of chronic ailment, intervenes with specific programs of care, measures clinical and other outcomes, and provides continuous quality improvement. Characterized as a movement to patient-driven services, DM involves a complex web of provider relations. (shrink)

Managed care is evolving in ways that pose unique ethical challenges to those interested in the intersection of clinical and organizational ethics. For example, Disease Management is a form of managed care that has emerged in response to chronic illness. DM is a healthcare management tool that coordinates resources across an entire health care delivery system and throughout the life cycle of chronic disease. Health Maintenance Organizations have reduced some costs in the delivery of acute care, but real (...) cost savings will result only with greater efficiencies in the delivery of costly chronic care. DM is a systematic, population-based approach that identifies persons at risk of chronic ailment, intervenes with specific programs of care, measures clinical and other outcomes, and provides continuous quality improvement. Characterized as a movement to patient-driven services, DM involves a complex web of provider relations. (shrink)

This article explores the relationship between gender, technology, language, and how infants and children born with disorders of sexual development are shaped into intelligible members of the community. The contemporary medical model maintains that children ought to be both socially and surgically assigned and reared as one particular gender. Gender scholar Suzanne Kessler rejects this position and argues for the acceptance of greater genital variability through the use of language. Using a Heideggerian lens, the main question I seek to (...) answer in this article is: does Kessler’s approach succeed in its aim to better treat individuals born with disorders of sexual development? I argue that Kessler is successful in offering practical solutions for persons with intersexed conditions to exist and flourish as intelligible members of the community, but that her project ultimately relies on power to “challenge forth” greater acceptance of genital variance. Building on the work of Kessler and Heidegger, I argue that a better approach to making intelligible the existence of an infant born with a disorder of sexual development is not to rely on the manipulation of language, but to instead reinvigorate a sense of the sacred in response to having an intersex condition. (shrink)

Katrina Karkazis, Fixing sex: Intersex, medical authority, and lived experience, Durham, N.C.: Duke University Press, 2008, reviewed by Ellen K. Feder Elizabeth Reis, Bodies in doubt: An American history of intersex, Baltimore: Johns Hopkins University Press, 2009, reviewed by Ellen K. Feder.

Anecdotes have shown that some articles on profitable drugs are constructed by and shepherded through publication by pharmaceutical companies and their agents, whose influence is largely invisible to readers. This is ghost-management, the substantial but unrecognized research, analysis, writing, editing and/or facilitation behind publication. Publicly available documents suggest that these practices extremely widespread affecting up to 40% of clinical trial reports in key periods but it has been unclear how representative these documents are. This article presents the results of (...) an investigative sampling of the self-presentation of publication planning services, and presents this and other evidence of a sizable publication planning industry. Thus different lines of evidence indicate that ghost-management is a common and important phenomenon, strongly affecting the published medical literature in the service of marketing. (shrink)

This article presents the first results of a study of the decisions made by health professionals in South Australia concerning the management of death, dying, and euthanasia, and focuses on the findings concerning the attitudes and practices of medical practitioners. Mail-back, self-administered questionnaires were posted in August 1991 to a ten per cent sample of 494 medical practitioners in South Australia randomly selected from the list published by the Medical Board of South Australia. A total response (...) rate of 68 per cent was obtained, 60 per cent of which (298) were usable returns. It was found that forty-seven per cent had received requests from patients to hasten their deaths. Nineteen per cent had taken active steps which had brought about the death of a patient. Sixty-eight per cent thought that guidelines for withholding and withdrawal of treatment should be established. Forty-five per cent were in favour of legalisation of active euthanasia under certain circumstances. (shrink)

The Management of Scientific Integrity within Academic Medical Centers discusses the impact scientific misconduct has in eight complex case studies. Authors look at multifaceted mixtures of improper behavior, poor communication, cultural issues, adverse medical/health issues, interpersonal problems and misunderstandings to illustrate the challenge of identifying and managing what went wrong and how current policies have led to the establishment of quasi legal processes within academic institutions. The book reviews the current global regulations and concludes with a section (...) authored by a US federal court judge who provides his perspective on the adequacy of current regulations and policies. (shrink)

The Italian code of medical deontology recently approved stipulates that physicians have the duty to inform the patient of each unwanted event and its causes, and to identify, report and evaluate adverse events and errors. Thus the obligation to supply information continues to widen, in some way extending beyond the doctor-patient relationship to become an essential tool for improving the quality of professional services.

This article explores the question of how scientific uncertainty can be managed in medical decision making using the Advisory Committee on Immunization Practices as a case study. It concludes that where a high degree of technical consensus exists about the evidence and data, decision makers act according to a clear decision rule. If a high degree of technical consensus does not exist and uncertainty abounds, the decision will be based on a variety of criteria, including readily available resources, decision-process (...) constraints, and the available knowledge base, among other things. Decision makers employ a variety of heuristic devices and techniques, thereby employing a pragmatic approach to uncertainty in medical decision making. The article concludes with recommendations for managing scientific uncertainty in medical decision making. (shrink)

Medication error is the most common and consistent type of error occurring in hospitals. This article attempts to explore the ethical issues relating to the nursing management of medication errors in clinical areas in Macau, China. A qualitative approach was adopted. Seven registered nurses who were involved in medication errors were recruited for in-depth interviews. The interviews were transcribed and analyzed using content analysis. Regarding the management of patients, the nurses acknowledged the mistakes but did not disclose the (...) incidents to patients and relatives. Concerning management of the nurses involved by senior staff, most participants experienced fairness, comfort and understanding during the process of reporting and investigation. The ethical issues relating to the incidents were discussed, particularly in the Chinese context. There is a need for further study relating to the disclosure of medication incidents to patients and some suggestions were made. (shrink)

In order to shorten queues to healthcare, the Swedish government has introduced a yearly “queue billion” that is paid out to the county councils in proportion to how successful they are in reducing queues. However, only the queues for first visits are covered. Evidence has accumulated that queues for return visits have become longer. This affects the chronically and severely ill. Swedish physicians, and the Swedish Medical Association, have strongly criticized the queue billion and have claimed that it conflicts (...) with medical ethics. Instead they demand that their professional judgments on priority setting and medical urgency be respected. This discussion provides an interesting illustration of some of the limitations of new public management and also more generally of the complicated relationships between medical ethics and public policy. (shrink)

The current debate about physician-assisted suicide and the question of whether patients would ask for such help if their pain were adequately controlled place in sharp focus the issue of undertreated pain. Studies have repeatedly documented the scope of the problem. A 1993 study of 897 physicians caring for cancer patients found that 86 percent of the physicians reported that most patients with cancer are undermedicated for their pain. A 1994 study found that noncancer patients receive even less adequate pain (...) treatment than patients with cancer-related pain, and that minority patients, the elderly, and women were more likely than others to receive inadequate pain treatment. Although the problem of undertreatment of pain is multifaceted, I only address how state medical boards contribute to the problem and suggest possible remedies.The literature on palliative care describes the numerous barriers that impede effective pain management and that result in the inadequate prescribing of pain-relieving drugs for terminally and chronically ill patients. (shrink)

The current debate about physician-assisted suicide and the question of whether patients would ask for such help if their pain were adequately controlled place in sharp focus the issue of undertreated pain. Studies have repeatedly documented the scope of the problem. A 1993 study of 897 physicians caring for cancer patients found that 86 percent of the physicians reported that most patients with cancer are undermedicated for their pain. A 1994 study found that noncancer patients receive even less adequate pain (...) treatment than patients with cancer-related pain, and that minority patients, the elderly, and women were more likely than others to receive inadequate pain treatment. Although the problem of undertreatment of pain is multifaceted, I only address how state medical boards contribute to the problem and suggest possible remedies.The literature on palliative care describes the numerous barriers that impede effective pain management and that result in the inadequate prescribing of pain-relieving drugs for terminally and chronically ill patients. (shrink)

Mistakes and errors happen in most spheres of human life and activity, including in medicine. A mistake can be as simple and benign as the collection of an extra and unnecessary urine sample. Or a mistake can cause serious but reversible harm, such as an overdose of insulin in a patient with diabetes, resulting in hypoglycemia, seizures, and coma. Or a mistake can result in serious and permanent damage for the patient, such as the failure to consider epiglottitis in an (...) initial differential diagnosis, resulting in a chronic vegetative state for a seven-year-old boy. Or a mistake can be an error in judgment that leads to a patient's death. (shrink)

: The market success of managed health plans in the 1990s is bringing to medicine the easy availability of electronically stored information that is characteristic of the securities and consumer credit industries. Protection for medical confidentiality, however, has not kept pace with this information revolution. Employers, the managed care industry, and legal and ethics commentators frequently look to the concept of informed consent to justify particular uses of health information, but the elastic use of informed consent as a way (...) of responding to managed health plans' disclosure of information to third parties fails to address underlying questions involving substantive value choices. (shrink)

The case study presented by Winch and Sinnott (2011) shows not only how difficult it is for clinicians and researchers to identify conflicts of interest (COI), but also how damaging it can be when there are unin- formed and uncoordinated policy responses by senior administrators.

Suicide is a leading cause of death in the United States and in many other parts of the world. As such, suicide is frequently framed as a medical and public health problem for which solutions are best recommended by medical and public health authorities. While, medicalized suicide prevention strategies often resonate with traditional Christian commitments to preserve life and to discourage suicide, there is little evidence to date that medical approaches to suicide risk-reduction decrease population rates of (...) suicide. Further, by treating suicide as a phenomenon that can be eliminated through technical managerial control, modern suicide prevention efforts construe suffering persons as carriers of risk best managed by standardized and often dehumanizing environments of care. This emphasis on the medical management of risk also erodes the clinician–patient relationship and inappropriately centers medical (e.g., systematic health screenings) rather than non-medical (e.g., access to housing) forms of response. Although, medicalized suicide prevention efforts should not be dismantled, those working to prevent suicide would do well to prioritize a positive commitment to human dignity and worth and to engage social and political systems beyond medicine and public health, while drawing on specific contributions that clinicians can offer. (shrink)

Where one stands to engage with the world is not as some New Age Psychologists continue to argue, completely free and self-determined. Rather, it is formed largely beyond one’s control and is fraught with both dangers and opportunities. This pre-determined point of view is referred to as the Assumptive World (Parkes, 1975). This is defined as a “strongly held set of assumptions about the world and the self that is confidently maintained and used as a means of recognizing, planning and (...) acting…Assumptions such as these are learned and confirmed by the experience of many years” (Parkes, 1975, p. 132). There are, further, levels and intensities of assumptions, as refined by Janoff-Bulman, R. (1992). These assumptions form the centre point of our world and our consciousness. They are so much a part of us that we tend not to challenge them. Though unchallenged, these assumptions nevertheless drive our behaviors, set our expectations, and operationalize our moral views. (shrink)

The increased competition for a share of the market of insured patients, which arose in the wake of failed comprehensive health care reform, has provoked questions about what, if any, standards will govern new “competitive” health care organizations. Managed care arrangements, which typically shift to providers and patients some or all of the financial risk for patient care, are of special concern because they can create incentives to withhold beneficial care from patients. Of course, fee-for-service medical practice creates incentives (...) to provide unnecessary services, and managed care can avoid that type of harm. Still, as Edmund Pellegrino has noted, “managed care, by its nature, places the good of the patient into conflict with … the good of all the other patients served by the plan; the good of the plan and the organization, themselves…; and the self-interest of the physician. (shrink)

The increased competition for a share of the market of insured patients, which arose in the wake of failed comprehensive health care reform, has provoked questions about what, if any, standards will govern new “competitive” health care organizations. Managed care arrangements, which typically shift to providers and patients some or all of the financial risk for patient care, are of special concern because they can create incentives to withhold beneficial care from patients. Of course, fee-for-service medical practice creates incentives (...) to provide unnecessary services, and managed care can avoid that type of harm. Still, as Edmund Pellegrino has noted, “managed care, by its nature, places the good of the patient into conflict with … the good of all the other patients served by the plan; the good of the plan and the organization, themselves…; and the self-interest of the physician. (shrink)

Physician concern about regulatory scrutiny as a barrier to appropriate prescribing for pain management has been identified and studied. A 1991 Pain Research Group survey demonstrated a need to provide updated information about opioids and pain management to state medical board members. Indeed, a national survey even showed a need to provide more education about pain management to oncology Physicians. Two approaches for responding to these concerns have been undertaken in several states by the state (...) class='Hi'>medical boards and the pain management community: the development and adoption of administrative policies designed to bring disciplinary standards in line with clinical practice; and the creation of education programs for state medical board members and staffs. Each can have a substantial impact on removing real and perceived regulatory barriers to effective pain relief. (shrink)

Physician concern about regulatory scrutiny as a barrier to appropriate prescribing for pain management has been identified and studied. A 1991 Pain Research Group survey demonstrated a need to provide updated information about opioids and pain management to state medical board members. Indeed, a national survey even showed a need to provide more education about pain management to oncology Physicians. Two approaches for responding to these concerns have been undertaken in several states by the state (...) class='Hi'>medical boards and the pain management community: the development and adoption of administrative policies designed to bring disciplinary standards in line with clinical practice; and the creation of education programs for state medical board members and staffs. Each can have a substantial impact on removing real and perceived regulatory barriers to effective pain relief. (shrink)

Medically unexplained symptoms (MUS) are common and costly in both primary and secondary health care. It is gradually being acknowledged that there needs to be a variety of interventions for patients with medically unexplained symptoms to meet the needs of different groups of patients with such chronic long-term symptoms. The proposed intervention described herewith is called The BodyMind Approach (TBMA) and promotes learning for self-management through establishing a dynamic and continuous process of emotional self-regulation. The problem is the mismatch (...) between the patient’s mind-set and profile and current interventions. This theoretical article, based on practice-based evidence, takes forward the idea that different approaches (other than cognitive behaviour therapy) are required for people with MUS. The mind-set and characteristics of patents with MUS are reflected upon to shape the rationale and design of this novel approach. Improving services for this population in primary care is crucial to prevent the iterative spiralling downwards of frequent GP visits, hospital appointments, and Accident and Emergency attendance, all of which are common for these patients. The approach derives from embodied psychotherapy (authentic movement in dance movement psychotherapy) and adult models of learning for self-management. It has been developed from research and practice-based evidence. In this article the problem of MUS in primary care is introduced and the importance of the reluctance of patients to accept a psychological/mental health referral in the first instance is drawn out. A description of the theoretical underpinnings and philosophy of the proposed alternative to current interventions is then presented related to the design, delivery, facilitation and educational content of the programme. The unique intervention is also described to give the reader a flavour. (shrink)

The arguments against managed care can be divided into two general clusters. One cluster concerns the way managed care undermines the ethical ideals of medical professionalism. Since those ideals largely focus on the physician-patient relation, the first cluster comes under the rubric of micro-ethics; namely, the ethics of individual-individual relations. The second cluster of criticisms focuses on macro-ethical issues, primarily on issues of justice and policy. By reviewing these arguments, it becomes clear that managed care does not easily fit (...) within traditional modes of ethical analysis. It poses a radical challenge to current medical and socio-political norms, and even resists the distinction between micro- and macro-ethical domains, a distinction that reflects the private/public distinction. Managed care organizations call for a third way, an inter-ethic for middle level organizations. The essays in this Journal provide a first step in this radical reassessment, laying the foundation for an organizational ethic that is responsive to the realities and promise of managed care. (shrink)

Increasing ethical attention and debate is focusing on whether individuals who take part in clinical trials should be given access to post-trial care. However, the main focus of this debate has been upon drug trials undertaken in low-income settings. To broaden this debate, we report findings from interviews with individuals (n = 24) who participated in a clinical trial of a closed-loop system, which is a medical device under development for people with type 1 diabetes that automatically adjusts blood (...) glucose to help keep it within clinically recommended ranges. Individuals were recruited from UK sites and interviewed following trial close-out, at which point the closed-loop had been withdrawn. While individuals were stoical and accepting of the requirement to return the closed-loop, they also conveyed varying degrees of distress. Many described having relaxed diabetes management practices while using the closed-loop and having become deskilled as a consequence, which made reverting back to pre-trial regimens challenging. Participants also described unanticipated consequences arising from using a closed-loop. As well as deskilling, these included experiencing psychological and emotional benefits that could not be sustained after the closed-loop had been withdrawn and participants reevaluating their pre- and post-trial life in light of having used a closed-loop and now perceiving this life much more negatively. Participants also voiced frustrations about experiencing better blood glucose control using a closed-loop and then having to revert to using what they now saw as antiquated and imprecise self-management tools. We use these findings to argue that ethical debates about post-trial provisioning need to be broadened to consider potential psychological and emotional harms, and not just clinical harms, that may result from withdrawal of investigated treatments. We also suggest that individuals may benefit from information about potential nonclinical harms to help make informed decisions about trial participation. (shrink)

Based on a medical corpus, this study attempts to capture how doctors manage their emotions and construct their professional identity in treatment discussions. Using the Emotion Model and the Model of Epistemics and Deontics Gradient, I find that when their professional expertise is questioned or doubted, doctors highlight their epistemic rights and displays negative emotions; when their professional role is negated, doctors give the deontic rights to their patients and discharge negative emotions; and when their professional ethics is challenged, (...) doctors project their professional morality, reinforce their deontic rights and give vent to negative emotions. This study, by integrating the Confucian System of Moral Virtues with Emotion Model, establishes a theoretical framework for examining the association between emotion management and identity construction in Chinese medical discourse. (shrink)