There has been significant debate about whether the moral norms of medical practice arise from some feature or set of features internal to the discipline of medicine. In this article, I analyze Edmund Pellegrino’s conception of the internal morality of medicine, and situate it in the context of Alasdair MacIntyre’s influential account of “practice.” Building upon MacIntyre, Pellegrino argued that medicine is a social practice with its own unique goals—namely, the medical, human, and spiritual good of the patient—and that the (...) moral norms that govern medical practice are derived from these goals. After providing an overview of Pellegrino’s work, I discuss some forceful objections to his theory—specifically, that it is too rigid and incapable of entering into dialogue with contemporary values systems; that it is dependent on an external conception of human flourishing; and that it is incompatible with the rapidly changing nature of modern medicine. In the final section of this article, I consider how theorists working in the Hippocratic tradition might respond to these objections against ethical essentialism by drawing upon MacIntyre’s historico-cultural method as well as what he calls Aristotle’s “metaphysical biology.”. (shrink)

Physicians and nurses need to sustain their unique strengths and work in true collaboration, recognizing their interdependence and the complementarity of their knowledge, skills and perspectives, as well as their common moral commitments. In this article, challenges often faced by both nurses and physicians in working collaboratively are explored with a focus on the ways in which each profession's preparation for practice has differed over time, including shifts in knowledge development and codes of ethics guiding their practice. A call for (...) envisioning their practice as shared moral work as well as practical strategies to begin that work are offered as a basis for reflection towards enhanced nurse-physician relationships. (shrink)

This article aims to describe underlying principles of paradigm shifts in clinical medicine by means of analysis of typical examples. Retrospectively, profound shifts of ruling paradigms can be shown in diverse fields such as outcome research, in the redefining of patient's and doctor's autonomies, in the challenges presented by consumer medicine and the free market economy. This has provoked controversy between doctors, patients and the community. The judgement on whether recent shifts in paradigms in medicine have improved the health care (...) delivered today is by no means uncontroversial. Aiming to demonstrate how shifts of paradigms in medicine occur and what consequences can result from such shifts we reflect on the works of Thomas S. Kuhn, the eminent philosopher of science. An analysis of his theories lends important insight into the observed shifts in paradigms. (shrink)

“Evidence based medicine” is often seen as a scientific tool for quality improvement, even though its application requires the combination of scientific facts with value judgments and the costing of different treatments. How this is done depends on whether we approach the problem from the perspective of individual patients, doctors, or public health administrators. Evidence based medicine exerts a fundamental influence on certain key aspects of medical professionalism. Since, when clinical practice guidelines are created, costs affect the content of EBM, (...) EBM inevitably becomes a form of rationing and adopts a public health point of view. This challenges traditional professionalism in much the same way as managed care has done in the US. Here we chart some of these major philosophical issues and show why simple solutions cannot be found. The profession needs to pay more attention to different uses of EBM in order to preserve the good aspects of professionalism. (shrink)

Among critics of corporate social responsibility (CSR), there is growing concern that CSR is largely ineffective as a corrective to the shortcomings of capitalism, namely, the negative effects of business on society and the undersupply of public goods. At the same time, researchers suggest that despite the shortcomings of CSR, it is possible to make it more effective in a stepwise manner. To explain the frequent failures of current CSR practices and to explore the possibilities of remedying them, I examine (...) the close relationship between CSR, the persistent expansion of capitalism, and the pressure that capitalism puts on companies to legitimize their business operations. My analysis shows that the failure of CSR to serve as a corrective to the problematic effects of capitalism is, in fact, an inevitable consequence of the problematic dynamics of the capitalist system. On this basis, I suggest that capitalism limits the possibilities of making CSR more effective, argue for change on the systemic level of capitalism, and explore the ways in which CSR research can contribute to this political endeavor. (shrink)

ABSTRACT Background: Experiencing ethical problems requires both ethically problematic situations and ethical sensitivity. Ethically problematic treatment decisions are distressing and might reflect health care quality problems. Whether all physicians actually experience ethical problems, what these problems are and how they vary according to physician age, gender and work sector are largely unknown. Methods: A mail survey of all non‐retired physicians licensed in Finland (n = 17,172, response rate 75.6%). Results: The proportion of physicians reporting having made ethically problematic treatment decisions (...) decreased in linear fashion from 60% at ages below 30 years to 21% at ages over 63 years. The only problem that did not decrease in frequency with age was having withdrawn necessary treatments. Women and primary care physicians reported problematic decisions most often, although gender differences were small. Primary care physicians most often reported having performed too many investigations or having pressured patients, whereas hospital physicians emphasized having withdrawn necessary treatments. Performing unnecessary treatments or investigations was explained by pressure from patients or relatives, and performing too few treatments or investigations was explained by inadequate resources. Conclusions: In general, young physicians felt pressured to do too much, whereas older physicians felt they could not do enough due to inadequate resources. Older physicians might be less exposed to ethically problematic situations, be more able to handle them or have lower ethical sensitivity. Young physicians could benefit from support in resisting pressure to perform unnecessary treatments, whereas older physicians might benefit from training in recognizing ethical issues. (shrink)

South Africa currently has a pluralistic health care system with separate public and private sectors. It is, however, moving towards a socialised model with the introduction of National Health Insurance. The South African legislative environment has changed recently with the promulgation of the Consumer Protection Act and proposed amendments to the National Health Act. Patients can now be viewed as consumers from a legal perspective. This has various implications for health care systems, health care providers and the doctor-patient relationship.

For at least the past several decades, medicine has been embroiled in a crisis concerning the nature of its professionalism. The fundamental questions that drive this ongoing crisis are primarily three. First, what is the nature of medical professionalism? Second, who are medical professionals? Third, what does medicine or these professionals profess or promise? In this paper, the professionalism crisis vis-à-vis these questions is examined and analyzed chiefly in terms of both Francis Peabody’s and Edmund Pellegrino’s writings. Based on their (...) writings, I introduce a conceptual framework for professionalism to address the crisis. In addition, I contend that to address the professionalism crisis adequately, medicine’s position within an evolving health care network must also be considered. To that end, I first discuss the genesis of the crisis in terms of the Flexner Report and especially Peabody’s response to it. Next, I explore how the crisis intensified during the twentieth century, particularly in terms of medicine’s ultimate scientification and eventual commercialization, and how Pellegrino reacted to this. I then propose a health care professionalism cycle and a care-competence cycle to provide a conceptual framework for addressing the crisis. I conclude that medicine’s position is no longer as the center of health care but rather as another node within a wider evolving health care network. And the resolution of medicine’s professionalism crisis depends on medicine’s positioning and defining itself in terms of the professionalism for each of the other professions within the health care network. (shrink)

Assisted reproductive technologies and abortion prompt serious questions about how we should understand the complex relationship between money, markets, choice, and the care relationship. This essay defines “patient” and “consumer,” and then describes how they are less important than their attributes. Then it describes theories of commodification and consumption in reproductive contexts and their consequences, from compliance and coercion to resistance and creativity. It also examines whether ART and abortion are “markets.” Finally, this essay explores how the attributes which comprise (...) the patient/consumer roles can be incorporated into health care reform, and the implications of health care reform models on ART and abortion. (shrink)

Edmund Pellegrino and David Thomasma’s writings have had a worldwide impact on discourse about the philosophy of medicine, professionalism, bioethics, healthcare ethics, and patients’ rights. Given their works’ importance, it is surprising that commentators have ignored their admission of an unresolved and troubling dilemma and inconsistency in their theory. The purpose of this article is to identify and state what problems worried them and to consider possible solutions. It is argued that their dilemma stems from their concerns about how to (...) justify professional rules restricting colleagues from performing acts they view as direct, active, and formal killings, such as physician-assisted suicide, mercy killing, and abortion. It is further argued that their inconsistency is that they both assert and deny that professional colleagues should not use their moral or theological values to impose professional restrictions on other colleagues without adequate philosophical grounds. At risk are their arguments about the nature of an internal morality for medicine, a secular and multicultural basis for medical ethics, and a nonarbitrary way to determine what acts fall outside the ends of medicine. These are arguments they claim also apply to other healthcare professions. The article begins with a brief overview of their key positions to provide the context in which they make their admission. (shrink)

Whereas bioethicists generally consider medicine a practice aimed at the individual good of each patient, in this paper I present an alternative conception of the goods of medicine. I first explain how modern liberal political theory gives rise to the predominant view of the medical good and then contrast this understanding of politics with that of Thomas Aquinas, informed by Aristotle. I then show how this Christian politics is implicit in certain aspects of contemporary medical practice and argue that Christians (...) ought to draw more attention to this point in order to direct medicine toward the common good. (shrink)

The rise and persistence of a commercial model of healthcare and the potential shift towards the commodification of dental services, provided to consumers, should provoke thought about the nature and purpose of dentistry and whether this paradigm is cause for concern. Within this article, whether dentistry is a commodity and the legitimacy of dentistry as a business is explored and assessed. Dentistry is perceived to be a commodity, dependent upon the context of how services are to be provided and the (...) interpretation of the patient–professional relationship. Commercially-focused practices threaten the fiduciary nature of the interaction between consumer and provider. The solution to managing commercial elements within dentistry is not through rejection of the new paradigm of the consumer of dental services, but in the rejection of competitive practices, coercive advertising and the erosion of professional values and duty. Consumerism may bring empowerment to those accessing dental services. However, if the patient–practitioner relationship is reduced to a mere transaction in the name of enhanced consumer participation, this empowerment is but a myth. (shrink)

is a review of 5 ethically based healthcare funding models discussed in the literature that are currently used to justify funding choices. If healthcare professionals and managers are better informed about the ethical reasoning behind funding choices, they could better determine which resource allocation alternatives to support. But where should we spend our resources? Although healthcare professionals have a duty to advocate for all healthcare recipients to receive a fair share of resources, the author concludes that our greater duty as (...) a profession is to the good of society as a whole. Balancing allocation decisions by considering all of the competing healthcare funding models and the ethical bases for them is suggested rather than to advocate too strongly for favored models.... (shrink)

This paper discusses the question whether care work for dependent persons (children, the elderly, and disabled persons) may be entrusted to the market; that is, whether and to what extent there is a normative justification for the “commodification of care.” It first proposes a capability theory for care that raises two relevant demands: a basic capability for receiving care and a capability for giving care. Next it discusses and rejects two objections that aim to show that market-based care undermines the (...) caring motives essential to care, one of them because of its reliance on contracts and the other because of the corrupting influence of payment on motivation. If market care is in principle legitimate, the commodification question transforms into one about the appropriate combinations of market and non-market care. This question can be answered only by adding an additional complication: care is to be balanced against other activities, most notably work for the labor market. This brings in the problem of gender inequality, since paid work has been traditionally distributed to men and caring activities to women. I show how the capability theory of caring presented in this paper can help resolve the dispute between competing models for balancing work and caring. (shrink)

Although the impact of market reforms in Swedish health care stands out as not very far-reaching in an international comparison, it represents a route away from the features and basic values normally associated with the Swedish or Scandinavian model. Summarizing the development over the last decades, we may identify signs of sustainability as well as change. Popular support for public provision and a robust institutional structure make far-reaching alterations of existing structures less feasible, although most visible changes this far—incremental though (...) they may be—represent a change in which the normative foundations of the Swedish model are challenged. (shrink)