The proposed revisions to Part Three of the Ethical and Religious Directives (ERDs)—on the professional-patient relationship—call attention to a number of timely, culturally relevant issues that require an understanding of the dignity of the human person and the true health of body, mind, and spirit. Several key issues newly discussed in these proposed revisions include transgender policies, the question of referrals for unethical clinical interventions, and triage and limited-resource allocation protocols for crisis situations. This paper draws on the theological (...) and philosophical basis forunderstanding the professional-patient relationship, especially in light of the metaphor of Christ the physician, in order to consider how the ERDs effectively address these key issues and promote true healing in Catholic health care. (shrink)

The conception of the doctor–patient relationship under Australian law has followed British common law tradition whereby the relationship is founded in a contractual exchange. By contrast, this article presents a rationale and framework for an alternative model—a “Trust Model”—for implementation into law to more accurately reflect the contemporary therapeutic dynamic. The framework has four elements: an assumption that professional conflicts with patient safety, motivated by financial or personal interests, should be avoided; an onus on doctors to disclose these (...) conflicts; a proposed mechanism to contend with instances where doctors choose not to disclose; and sanctions for non-compliance with the regime. (shrink)

Bioethics is a subject far removed from the Chinese, even from many Chinese medical students and medical professionals. In-depth interviews with eighteen physicians, patients, and family members provided a deeper understanding of bioethical practices in contemporary China, especially with regard to the doctor-patient relationship (DPR) and informed consent. The Chinese model of doctor-family-patient relationship (DFPR), instead of DPR, is taken to reflect Chinese Confucian cultural commitments. An examination of the history of Chinese culture and the profession of medicine (...) in China is used to disclose the deep roots of these commitments. The author predicts that the DFPR model will further develop in China but that it will maintain its Chinese character. (shrink)

The aim of this study was to report the results of a literature review of empirical studies on trust within the nurse–patient relationship. A search of electronic databases yielded 34 articles published between 1980 and 2011. Twenty-two studies used a qualitative design, and 12 studies used quantitative research methods. The context of most quantitative studies was nurse caring behaviours, whereas most qualitative studies focused on trust in the nurse–patient relationship. Most of the quantitative studies used a descriptive design, (...) while qualitative methods included the phenomenological approach, grounded theory, ethnography and interpretive interactionism. Data collection was mainly by questionnaires or interviews. Evidence from this review suggests that the development of trust is a relational phenomenon, and a process, during which trust could be broken and re-established. Nurses’ professional competencies and interpersonal caring attributes were important in developing trust; however, various factors may hinder the trusting relationship. (shrink)

Health care is not merely a matter of individual encounters between patients and physicians or other health care personnel. For patients and those who provide health care come to these encounters already possessed of learned habits of perception and judgment, valuation and action, which define their roles in relation to one another and affect every aspect of their encounter. So the presuppositions of these encounters must be examined if our understanding of patients' autonomy is to be complete. In this paper (...) I sketch three models of what is presupposed in the relationship between the health care professional and the lay patient; and I discuss the ways in which patients' autonomy is preserved and/or compromised under each of the three models. The models discussed are the Guild Model, the Commercial Model, and the Interactive Model. (shrink)

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. (shrink)

Introducción: la formación de profesionales competentes es una de las misiones esenciales de la Educación Médica Superior, esto exige que los tecnólogos posean habilidades comunicativas para un correcto desempeño laboral en aras del mejoramiento humano. Objetivo de la investigación: identificar las barreras que inciden en la comunicación tecnólogo - paciente en las carreras de Licenciatura en Traumatología, Podología, Terapia Física y Rehabilitación Social Ocupacional, en áreas de rehabilitación. Métodos: se presenta un estudio observacional, descriptivo longitudinal y retrospectivo entre junio de (...) 2008 y junio 2011 que consistió en la observación a exámenes estatales prácticos y a la educación en el trabajo, en las carreras de referencia, además se aplicó una encuesta a pacientes para la obtención de información acerca de las barreras que afectan el proceso de la comunicación entre tecnólogos y pacientes. Resultados: existen insuficiencias en la comunicación entre los futuros profesionales y pacientes. Conclusiones: se demuestra un insuficiente dominio de las habilidades comunicativas y por tanto barreras que interfieren en la comunicación como las semánticas y personales. Introduction: the training of competent professionals is one of the essential missions of higher medical education; this requires that technologists have communication skills in order to develop a proper job performance for the sake of human improvement. So the objective of the research is to identify barriers affecting technologist - patient communication in the careers of degree in Trauma, Podiatry, Physical Therapy, and Occupational Social Rehabilitation in areas of rehabilitation. Methods: an observational, longitudinal descriptive and retrospective study is presented between June 2008 and June 2011 that consisted on observation to practical state exams and training at work, in the reference degrees; in addition, a survey was applied to patients to obtain information about the barriers that affect the communication process between technologists and patients. Results: there are communication inadequacies between the future professionals and patients. Conclusions: An insufficient mastery of the communication skills is demonstrated and therefore barriers that interfere with communication as the semantic and personal barriers. (shrink)

Boundaries in the doctor–patient relationshipis an important concept to help healthprofessionals navigate the complex andsometimes difficult experience between patientand doctor where intimacy and power must bebalanced in the direction of benefitingpatients. This paper reviews the concept ofboundary violations and boundary crossings inthe doctor–patient relationship, cautions aboutcertain kinds of boundary dilemmas involvingdual relationships, gift giving practices,physical contact with patients, andself-disclosure. The paper closes with somerecommendations for preventing boundaryviolations.

This paper explores the nature of trust in nurse–patient relationships from the perspective of the patient's trust in the nurse and what might be said to then render such a relationship trustworthy, from the patient's point of view. The paper commences with a general examination of the nature of trust, followed by consideration of the nature of professional–patient relationships in healthcare, with emphasis on nurse– patient relationships in particular. The nature of this relationship is used to provide grounds (...) for arguing, both morally and conceptually, that the nature of patients’ trust in those who nurse them is generally such that for the nurse to respond in a trustworthy way, she must care about her patients, not just for them. In arriving at this conclusion, the paper deliberately restricts its focus to nurse–patient encounters where patients are adults and a relationship, as opposed to a brief engagement between two people, can be said to have taken place. The context for this focus is public sector health care in the United Kingdom. In the text, gendered pronouns referring to doctors, nurses and patients are meant to be inclusive of both sexes. (shrink)

Background The ambulance service provides emergency care to meet the patient’s medical and nursing needs. Based on professional nursing values, this should be done within a caring relationship with a holistic approach as the opposite would risk suffering related to disengagement from the patient’s emotional and existential needs. However, knowledge is sparse on how ambulance personnel can meet caring needs and avoid suffering, particularly in conjunction with urgent and emergency situations. Aim The aim of the study was to explore (...) ambulance nurses’ experiences of relationships with patients in urgent and emergency situations. Methods Data collection was performed using individual open-ended interviews with six ambulance nurses. The data were analyzed using a thematic analysis. Results Relationships with patients during urgent and emergency assignments emerged as three themes: “ Ambiguous silence,” “ Professional competence” and “ Challenging inadequacy” comprising eight sub-themes in total. The result shows that the ambulance nurses found it difficult to prioritize between medical care and establishing a caring relationship with the patient. However, sometimes a wordless relationship was perceived sufficient and considered a first step towards a verbal relationship. Conclusions Ambulance nurses experience that a caring relationship cannot and does not need to be prioritized in the acute stage. This uncovers a dichotomy approach to medical care versus caring relationships that exclude a holistic approach. Thus, patients’ emotional, existential and physical needs are not considered as equally important. Clinical relevance: It is important to stimulate reflection on core ethical nursing values, in training and simulation exercises among clinically active ambulance nurses. (shrink)

This essay focuses on the doctor-patient relationship as a measure of ethical behavior by the physician. The perspective is derived from commitment as a religious humanist to the Judaic heritage, and experience in hospitals. The ethical responsibility to be competent professionally is presupposed. Emphasis is placed on the need of the physician to respect the autonomy of the patient as person, thus to limit the paternalism inherent in the physician's position, and to re-enforce this with compassion. Judaic sources supporting (...) such conduct are cited. Exception is taken to decisions by civil and rabbinic judges which disregard the intimacy of the doctor-patient relationship. Keywords: doctor-patient relationship, bioethics, Judaism, compassion, paternalism, autonomy CiteULike Connotea Del.icio.us What's this? (shrink)

This article examines one aspect of the criticism of inauthenticity that can be levelled against the trustworthiness of professional relationships in general and nurse-patient relationships in particular. The overall question is: are such relationships inherently trustworthy or untrustworthy, from the patient’s point of view? The author concludes that, in spite of legitimate grounds for concern, and while it remains true that nurse-patient relationships may be untrustworthy, they are not inherently so for reasons of inauthenticity relating to emotional labour. The arguments (...) used to defend this claim take their force from the idea that different criteria may be needed to assess the authenticity of nurse-patient relationships from those used to evaluate authenticity in ordinary social relationships. The utility of Hochschild’s idea of ‘deep’ acting, as offering a useful model for the management of emotions in nursing, is examined and rejected. (shrink)

In April 1991, a general meeting of the Japanese Medical Conference was held in Kyoto and attracted 32,500 participants, the largest number ever. The theme of the meeting was “Medicine and Health Care in Transition,” and the program Included panel discussions on “How to Promote the Quality of Health Care” and “How Terminal Care Should Be Provided” and symposia on “Diagnosis of Brain Death and Its Problems,” “The Propriety of Organ Transplantation,” and “Brain Death and Organ Transplantation.” These titles reveal (...) not only how medical professionals in Japan perceive the present situatior healthcare but also the Issues that most concern them. (shrink)

Ensuring patient participation in healthcare decision making remains a difficult task. Factors such as a lack of time in the consultation, medical objectivation, or the difficulties of translating individual patient experience into the treatment plan have been shown to limit patient contributions. Little research attention has focused however on how emotions experienced by both the patient and the healthcare provider may affect the ability of the patient to participate. In this research, patient’s and healthcare provider’s emotions were identified and analysed. (...) The research method showed fear as a prominent emotion experienced. This included patient’s fears both inside and outside the consultation, as well as the healthcare provider’s fears in their professional practice. Using Martha Nussbaum’s cognitive-evaluative theory of emotions as an additional means of analysis, the research looked at what this emotion could show about the importance of the object of this fear to the person’s eudaimonia (flourishing). At the end of the article, several solutions were proposed to help mitigate this fear to keep it from becoming a destructive force in the healthcare provider—patient relationship. (shrink)

The doctors -- The patients -- "Misunderstandings".

Beginning my third year with the Kansas City Chiefs and being also a medical student at McGill University, I was at first a little reluctant to comment on Glenn Cohen et al.’s critique of the National Football League's structure involving player health and team doctors, but the opportunity to provide a perspective as both a football player and a medical student was too much to forgo. Because of my athletic and academic background, I am often asked what I think about (...) injuries in professional sports and about the role of sports medicine physicians, and Cohen et al.’s article demands a thoughtful reaction. I want to suggest that the fundamental principles concerning the medical profession and the doctor-patient relationship provide additional arguments for some of the solutions that Cohen et al. discuss. The professional self-regulation that the proposed medical committee could provide and the reliance on a doctor who was not hired by the player's employer—the club—for a second opinion are both good ways to minimize conflicts of interest. (shrink)

Ethnic minority patients face challenges concerning communication and are at higher risk of experiencing health problems and consuming fewer healthcare services. They are also exposed to disparaging societal discourses about migrants which might undermine healthcare institutions’ ambitions of equitable health care. Therefore, healthcare professionals need to critically reflect on their practices and processes related to ethnic minority patients. The aim of this article is to explore healthcare professionals’ experiences of working with ethnic minority patients by using the critical incident (CI) (...) technique. In two focus group sessions, participants discussed challenging events in their encounters with patients. The critical incidents show that healthcare professionals may experience unfamiliar situations related to their work performance, prejudice toward patients, and labeling by patients the professionals do not identify with. The professionals’ reflections are discussed in relation to social discourses on migration and their work conditions, and the possible influence on the professionals’ preconceptions and the patient–professional relationship in health care. Reflections about work experiences with ethnic minority patients and aligned societal discourses should be included in healthcare workers’ professional development. Critical incident reflections at work may contribute to better‐coping strategies for healthcare professionals and improved patient–professional relationships with ethnic minority patients. (shrink)

Background Paternalism/overprotection limits communication between healthcare professionals and patients and does not promote shared therapeutic decision-making. In the global north, communication patterns have been regulated to promote autonomy, whereas in the global south, they reflect the physician’s personal choices. The goal of this study was to contribute to knowledge on the communication patterns used in clinical practice in Mexico and to identify the determinants that favour a doctor–patient relationship characterized by low paternalism/autonomy. Methods A self-report study on communication patterns (...) in a sample of 761 mental healthcare professionals in Central and Western Mexico was conducted. Multiple ordinal logistic regression models were used to analyse paternalism and associated factors. Results A high prevalence of paternalism was observed among mental health professionals in Mexico. The main determinants of low paternalism/autonomy were medical specialty and gender, with female physicians being more likely to explicitly share diagnoses and therapeutic strategies with patients and their families. A pattern of highly explicit communication was strongly associated with low paternalism/autonomy. Finally, a modifying effect of age strata on the association between communication pattern or specialty and low paternalism/autonomy was observed. Conclusions Among mental health professionals in Mexico, high paternalism prevailed. Gender, specialty, and a pattern of open communication were closely associated with low paternalism/autonomy. Strengthening health professionals’ competencies and promoting explicit communication could contribute to the transition towards more autonomist communication in clinical practice in Mexico. The ethical implications will need to be resolved in the near future. (shrink)

Background In the course of the last four decades, the profession of physiotherapy has progressively expanded its scope of responsibility and its focus on professional autonomy and evidence-based clinical practice. To preserve professional autonomy, it is crucial for the physiotherapy profession to meet society's expectations and demands of professional competence as well as ethical competence. Since it is becoming increasingly popular to choose a carrier in private practice in Denmark this context constitutes the frame of this study. Physiotherapy in private (...) practice involves mainly a meeting between two partners: the physiotherapist and the patient. In the meeting, power asymmetry between the two partners is a condition that the physiotherapist has to handle. The aim of this study was to explore whether ethical issues rise during the first physiotherapy session discussed from the perspective of the physiotherapists in private practice. Methods A qualitative approach was chosen and semi-structured interviews with 21 physiotherapists were carried out twice and analysed by using a phenomenological framework. Results Four descriptive themes emerged: general reflections on ethics in physiotherapy; the importance of the first physiotherapy session; the influence of the clinical environment on the first session and; reflections and actions upon beneficence towards the patient within the first session. The results show that the first session and the clinical context in private practice are essential from an ethical perspective. Conclusions Ethical issues do occur within the first session, the consciousness about ethical issues differs in Danish physiotherapy private practice, and reflections and acts are to a lesser extent based on awareness of ethical theories, principles and ethical guidelines. Beneficence towards the patient is a fundamental aspect of the physiotherapists' understanding of the first session. However, if the physiotherapist lacks a deeper ethical awareness, the physiotherapist may reason and/or act ethically to a varying extent: only an ethically conscious physiotherapist will know when he or she reflects and acts ethically. Further exploration of ethical issues in private practice is recommendable, and as management policy is deeply embedded within the Danish public sector there are reasons to explore public contexts of physiotherapy as well. (shrink)

Metaphors are central in communication and sense-making processes in health-related contexts. Yet how the metaphors used by health-care-professionals to make sense of their patients and their relations to them are associated to the perceived valence of their clinical encounters is underexplored. Drawing-upon the ABC Model of Dehumanization, this study investigated how the humanizing or dehumanizing metaphors nurses’ use for making sense of their pain patients are associated with how they perceived their relationships with them. Fifty female nurses undertook individual narrative-episodic (...) interviews about easy/difficult cases in pain care. A content analysis classified the metaphors, identifying eight classes reflecting different types of patients (de)humanization. A multiple correspondence analysis extracted patterns of metaphors and their association with the perceived characteristics of the patient-nurse relationship. It showed how these patterns were not associated with patient sex or socioeconomic status (SES) but were related to the perceived valence of the clinical relationship. By uncovering how patient metaphors guide nurses’ sense-making and potentially modulate interactions in clinical encounters, these findings may contribute to improve quality of pain care. (shrink)

One of the largest, oldest, and most interesting challenges in health care is the balancing act in which clinicians have generally uncontroversial duties both to individual patients and to communities. Physicians and nurses must — so we teach them — put patients first, and at the same time recognize that individuals are members of communities. Individuals affect the health of communities, and communities affect the health of individuals. Thus, the moral and professional duties that result are sometimes in conflict.Moreover, the (...) traditional, prosaic clinical encounter is evolving in an environment increasingly shaped by electronic health records, personal health records, pharmacogenomics and vast networks of data collection and storage for public health surveillance, human subjects research, health services evaluation, and comparative effectiveness research. Health information technology is changing everything. It would be perverse otherwise: imagine large amounts of data and information either ignored, missed, or collected and then ignored. (shrink)

Objectives: To assess French district nurses’ opinions towards euthanasia and to study factors associated with these opinions, with emphasis on attitudes towards terminal patients.Design and setting: An anonymous telephone survey carried out in 2005 among a national random sample of French district nurses.Participants: District nurses currently delivering home care who have at least 1 year of professional experience. Of 803 district nurses contacted, 602 agreed to participate .Main outcome measures: Opinion towards the legalisation of euthanasia , attitudes towards terminal patients (...) .Results: Overall, 65% of the 602 nurses favoured legalising euthanasia. Regarding associated factors, this proportion was higher among those who discuss end-of-life issues with terminal patients , who consider competent patients should always be told their prognosis and who value the role of advance directives and surrogates in end-of-life decision-making for incompetent patients . Women and older nurses were less likely to favour legalising euthanasia, as were those who believed in a god who masters their destiny.Conclusions: French nurses are more in favour of legalising euthanasia than French physicians; these two populations contrast greatly in the factors associated with this support. Further research is needed to investigate how and to what extent such attitudes may affect nursing practice and emotional well-being in the specific context of end-of-life home care. (shrink)

BackgroundWe examine the incidence of medical tribunal decisions and disciplinary actions (DAs) against healthcare professionals (HCPs). In addition, we studied whether an intimate relationship between an HCP and patient as part of the medical tribunal decision is associated with an increased likelihood of disciplinary actions.MethodsWe conducted a nationwide cohort analysis on the downloadable medical tribunal decisions from a medical disciplinary tribunal in the Netherlands from 2010 to 2017.ResultsWe found that 117 (2.8%) of the 4,046 medical tribunal decisions involved an (...) alleged intimate relationship between an HCP and patient. In these medical tribunal decisions the likelihood of a disciplinary action was significantly increased (odds ratio [OR] 12.97, 95% Confidence Interval [95% CI] 7.11–23.64). In addition, we found that nurses and psychiatrists are more frequently accused of and receive disciplinary actions due to intimate relationships than other HCP groups.ConclusionsWe found a limited number of medical tribunal decisions involving an intimate relationship. Especially given the total number of medical tribunal decisions and the number of yearly HCP-patient interactions, the number appears small. Furthermore, an alleged intimate relationship or inappropriate sexual conduct is associated with an increased likelihood of disciplinary action. Future research should obtain statistics on the number of intimate relationships that actually start between HCPs and patients. (shrink)

The American Medical Association enacted its Code of Ethics in 1847, the first such national codification. In this volume, a distinguished group of experts from the fields of medicine, bioethics, and history of medicine reflect on the development of medical ethics in the United States, using historical analyses as a springboard for discussions of the problems of the present, including what the editors call "a sense of moral crisis precipitated by the shift from a system of fee-for-service medicine to a (...) system of fee-for-system medicine, better known as 'managed care.'" The authors begin with a look at how the medical profession began to consider ethical issues in the 1800s and subsequent developments in the 1900s. They then address the sociological, historical, ethical, and legal aspects of the practice of medicine. Later chapters discuss current and future challenges to medical ethics and professional values. Appendixes display various versions of the AMA's Code of Ethics as it has evolved over time. Contributors: George J. Annas, J.D., M.P.H., Arthur Isak Applbaum, Ph.D., Robert B. Baker, Ph.D., Chester R. Burns, M.D., Ph.D., Arthur L. Caplan, Ph.D., Alexander Morgan Capron, J.D., Christine K. Cassel, M.D., Linda L. Emanuel, M.D., Ph.D., Eliot L. Freidson, Ph.D., Albert R. Jonsen, Ph.D., Stephen R. Latham, J.D., Ph.D., Susan E. Lederer, Ph.D., Florencia Luna, Ph.D., Edmund D. Pellegrino, M.D., Charles E. Rosenberg, Ph.D., Mark Siegler, M.D., Rosemary A. Stevens, Ph.D., Robert M. Tenery, Jr., M.D., Robert M. Veatch, Ph.D., John Harley Warner, Ph.D., Paul Root Wolpe, Ph.D. (shrink)

Recognising a diminution in his emotional response to patients’ deaths, the author analyses in detail his internal reactions in an attempt to understand what he believes is a common phenomenon among doctors. He identifies factors that may erode the connection between patient and physician: an instinct to separate oneself from another’s suffering, professional unease in the case of therapeutic failure, the atrophying effect of perceived hopelessness, insincerities in the establishment of the initial relationship, and an inability to imbue the (...) sedated or unconscious patient with human qualities. He concludes that recognition of these negative influences, without necessarily changing behaviours that are natural, may be a first step towards protecting doctors against what might be an otherwise insidious process of dehumanisation. (shrink)

This article presents evidence regarding aspects of the gendered nature of care women with gynaecological cancer receive from their (usually) male surgeons and oncologists in Australia. We argue that despite women’s general preference for female gynaecologists, those with a gynaecological cancer develop a strong therapeutic relationship with their male medical specialist, not extended to their (usually) female nurses and other allied health professionals. Given the highly sensitive and sexualized nature of gynaecological cancer, this requires explanation. These findings can be (...) partly explained by examining the division of labour between nurses and doctors, specifically issues of control over this process and the development of specializations. The findings also bring into stark relief the way in which power and status differences can be used by medicine to create a positive therapeutic relationship with patients while simultaneously de-eroticizing the intimate procedures necessary in assisting women throughout their cancer treatment. Importantly, this relationship also has relevance for policy makers, particularly those concerned with the highly gendered division of labour of the medical specialty workforce in Australia. (shrink)

In an era of transition and tension in American health care, Dorothy M. Owens offers a model of empathic communication that benefits both patients and physicians. Drawing from concepts in the domains of psychology and theology, she constructs a model of empathy that is ethical and reciprocal. An integrated model of empathy recognizes the physical, psychological, spiritual, and social nature of human beings. Empathy is a clinically useful, time-effective communication skill that can be taught in medical and pastoral education. Dr. (...) Owens's unique approach to empathy is applicable to other professional and personal relationships as well. (shrink)

Aim To examine the contribution of programme year and demographic factors to medical students’ perceptions of evidence-based classification categories of professional misconduct. Methods Students at an Irish medical school were administered a cross-sectional survey comprising 31 vignettes of professional misconduct, which mapped onto a 12-category classification system. Students scored each item using a 5-point Likert scale, where 1 represents the least severe form of misconduct and 5 the most severe. Results Of the 1012 eligible respondents, 561 students completed the survey, (...) providing a response rate of 55%. Items pertaining to disclosure of conflict of interest were ranked as the least severe examples of professional misconduct, and this perception was highest among finalyear students. While ratings of severity declined for items related to ‘inappropriate conduct not in relation to patient’ and ‘inappropriate use of social media’ between years 1 and 3, ratings for both categories increased again among clinical cycle students. Conclusions Increased clinical exposure during years 4 and 5 of the undergraduate programme was associated with better recognition of the importance of selected professional domains. Disclosure of conflict of interest is identified as an area of medical professionalism that requires greater emphasis for students who are at the point of transition from student to doctor. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:“Can They Do This?” Dealing with Moral Distress after Third–Party Termination of the Doctor–Patient RelationshipSusan McCammonNot so long ago, a storm badly damaged the tertiary care hospital in which I practice surgical oncology. In the aftermath of the storm, the institution determined it was no longer able to provide unreimbursed cancer care, and many of my patients were terminated by a form letter from the hospital. The helplessness and (...) outrage that I experienced when I was first handed one of these letters, crumpled from the damp fist of one of my patients, was immense, and frightening in its unfamiliarity: “Can they do this?” I asked repeatedly, ascending a hierarchy of authority, which was increasingly reticent and then elusive. In short, the answer was “yes.”While this decision was made by the administration, its enactment was delegated to the physicians. Thus, not only were the physicians not involved in the decision to terminate their patients, they shouldered the burden of telling their patients that they would no longer be treated. The reason given—storm devastation—was contradicted by the orderly flow of insured patients in and out of unaffected clinics and hospitals.In those months, when the operating rooms were closed, I took to the road and learned about hospice and palliative care medicine on the ground. I drove from city to smaller city to the devastated countryside, locating my patients and providing all the care that I could with only my hands and mind and heart. I struggled with the limitations of the health care system and worked to rebuild a sustainable infrastructure at my own institution, all while trying to come to terms with bioethicist Haavi Morreim’s (1995) caution that “... it is not the physician who owes the resources at all. He cannot owe what others own and control, because moral obligations can only be assigned to those capable of fulfilling them” (p. 87).In considering my experience of moral distress over this period of time, I have reflected on the different connotations of the word, “practice.” I grappled with the philosophical terms “practice,” “praxis,” and “phronesis,” and I questioned their relevance to the word, as used in my professional life. However, in struggling to understand my moral obligations after the storm, when I was learning to do what I could, even when I couldn’t do what I felt like I should, I reconsidered. The elements of immersion, repetition, particularity, and utility that pervade this language of philosophers and artists turned out to be what preserved my ability [End Page 109] to practice medicine in a space holding only patient and practitioner.Many of the patients that I take care of are very poor. Many more are working but uninsured. This is a result of both their risk factors and the demographics and resources in my geographic catchment area. Their access to care was disrupted after a natural disaster and concerted efforts to reestablish it have not succeeded. Since then, I have learned how to tell people that they will die of cancer because they don’t have enough money. This is not a skill I was taught in medical school. I can talk about death, imminent or not, feared or anticipated. I can talk about unresectable tumors, treatments that have more risk than benefit (or no benefit at all), suffering beyond what has yet been experienced or imagined, helplessness, futility and grief. I could be neither surgeon nor oncologist without some facility with these. But I was unprepared for this move from medical to economic “can’t,” the nexus where an institutional “won’t” becomes a personal “can’t.”I should say here that I was not blind to the expense and technological hype of the American medico–industrial complex or our systematic marginalization of public health or the ever–present cries for health care reform. I understood that I was a steward and that I served both the individual and the society and had at my disposal what I was told were limited resources. These values, however, were only just being incorporated into the training of medical professionals; certainly they played no role in my own education. Morreim’s (1995) conclusion... (shrink)

This paper proposes a refocusing of consent for clinical genetic testing, moving away from an emphasis on autonomy and information provision, towards an emphasis on the virtues of healthcare professionals seeking consent, and the relationships they construct with their patients. We draw on focus groups with UK healthcare professionals working in the field of clinical genetics, as well as in-depth interviews with patients who have sought genetic testing in the UK’s National Health Service. We explore two aspects of consent: first, (...) how healthcare professionals consider the act of ‘consenting’ patients; and second how these professional accounts, along with the accounts of patients, deepen our understanding of the consent process. Our findings suggest that while healthcare professionals working in genetic medicine put much effort into ensuring patients’ understanding about their impending genetic test, they acknowledge, and we show, that patients can still leave genetic consultations relatively uninformed. Moreover, we show how placing emphasis on the informational aspect of genetic testing is not always reflective of, or valuable to, patients’ decision-making. Rather, decision-making is socially contextualised – also based on factors outside of information provision. A more collaborative on-going consent process, grounded in virtue ethics and values of honesty, openness and trustworthiness, is proposed. (shrink)

This paper discusses a number of critical ethical problems that arise in interactions between queer patients and health care professionals attending them. Using real-world examples, we discuss the very practical problems queer patients often face in the clinic. Health care professionals face conflicts in societies that criminalise same sex relationships. We also analyse the question of what ought to be done to confront health care professionals who propagate falsehoods about homosexuality in the public domain. These health care professionals are more (...) often than not motivated by strong religious convictions that conflict with mainstream medical opinion on homosexuality. We argue that they ought to be held accountable for their conduct by their professional statutory bodies, given that they abuse their professional standing to propagate sectarian views not representative of their profession. Lastly, we propose that medical schools have special responsibilities in training future health care professionals that will enable them to respond professionally to queer patients seeking health care. (shrink)

The purpose of this paper is to evaluate the significance of the existential notion of authenticity for medical ethics. This is done by analyzing authenticity and examining its implications for the patient-professional relationship and for ethical decision-making in medical situations. It is argued that while authenticity implies important demand for individual responsibility, which has therapeutic significance, it perpetuates ideas which are antithetical both to authentic interaction between patients and professionals and to fruitful deliberation of moral dilemmas. In order to (...) counteract these consequences, an alternative idea of authenticity is introduced. According to this idea, authenticity is not regarded primarily as individual sovereignty, but as an ability to participate in a dialogue in which the subjectivity of both partners is respected. Such practice, based on mutual trust and responsibility, would enhance common decision-making and overcome the alienation between patients and professionals. (shrink)

Background: In the course of the last four decades, the profession of physiotherapy has progressively expanded its scope of responsibility and its focus on professional autonomy and evidence-based clinical practice. To preserve professional autonomy, it is crucial for the physiotherapy profession to meet society's expectations and demands of professional competence as well as ethical competence. Since it is becoming increasingly popular to choose a carrier in private practice in Denmark this context constitutes the frame of this study. Physiotherapy in private (...) practice involves mainly a meeting between two partners: the physiotherapist and the patient. In the meeting, power asymmetry between the two partners is a condition that the physiotherapist has to handle. The aim of this study was to explore whether ethical issues rise during the first physiotherapy session discussed from the perspective of the physiotherapists in private practice. Methods: A qualitative approach was chosen and semi-structured interviews with 21 physiotherapists were carried out twice and analysed by using a phenomenological framework. Results: Four descriptive themes emerged: general reflections on ethics in physiotherapy; the importance of the first physiotherapy session; the influence of the clinical environment on the first session and; reflections and actions upon beneficence towards the patient within the first session. The results show that the first session and the clinical context in private practice are essential from an ethical perspective. Conclusions: Ethical issues do occur within the first session, the consciousness about ethical issues differs in Danish physiotherapy private practice, and reflections and acts are to a lesser extent based on awareness of ethical theories, principles and ethical guidelines. Beneficence towards the patient is a fundamental aspect of the physiotherapists' understanding of the first session. However, if the physiotherapist lacks a deeper ethical awareness, the physiotherapist may reason and/or act ethically to a varying extent: only an ethically conscious physiotherapist will know when he or she reflects and acts ethically. Further exploration of ethical issues in private practice is recommendable, and as management policy is deeply embedded within the Danish public sector there are reasons to explore public contexts of physiotherapy as well. (shrink)

Patient’s decision making competence is a widely discussed subject. Issues of competence, autonomy, well-being and protection of the patient come up every day. In this article we analyse what role PDMC plays in Dutch legislation and what dilemmas healthcare professionals may experience, notably in patients suffering from Korsakoff’s syndrome. Dilemmas emerge if professionals want to meet the requirements mentioned in Dutch law and the desires of their patients. The autonomy of the patient and the healthcare professionals’ duty to take care (...) of their patient’s best interests, create a tension and lead to uncomfortable situations. Healthcare professionals describe difficulty finding a balance between these issues and assessing the degree of mental competence still present. In long term care situations, quality of the relationship between healthcare professionals and their patients seems to be of much more importance in decision making on minor issues of competence than simply relying on legal or house rules. In being committed to their cases, professionals will be more sensitive to individuals habits, abilities, welfare and dignity, which will make it easier to decide on issues of competence, and to find creative solutions to their dilemmas. (shrink)

BackgroundPrecision medicine development is driven by the possibilities of next generation sequencing, information technology and artificial intelligence and thus, raises a number of ethical questions. Empirical studies have investigated such issues from the perspectives of health care professionals, researchers and patients. We synthesize the results from these studies in this review.MethodsWe used a systematic strategy to search, screen and assess the literature for eligibility related to our research question. The initial search for empirical studies in five data bases provided 665 (...) different records and we selected 92 of these publications for inclusion in this review. Data were extracted in a spreadsheet and categorized into different topics representing the views on ethical issues in precision medicine.ResultsMany patients and professionals expect high benefits from precision medicine and have a positive attitude towards it. However, patients and professionals also perceive some risks. Commonly perceived risks include: lack of evidence for accuracy of tests and efficacy of treatments; limited knowledge of patients, which makes informed consent more difficult; possible unavailability of access to precision medicine for underprivileged people and ethnic minorities; misuse of data by insurance companies and employers, potential of racial stigmatization due to genetic information; unwanted communication of incidental findings; changes in doctor-patient-relationship through focusing on data; and the problem that patients could feel under pressure to optimize their health.ConclusionsNational legislation and guidelines already minimize many risks associated with precision medicine. However, from our perspective some problems require more attention. Should hopes for precision medicine’s benefits be fulfilled, then the ethical principle of justice would require an unlimited access to precision medicine for all people. The potential for autonomous patients’ decisions must be greatly enhanced by improvements in patient education. Harm from test results must be avoided in any case by the highest possible data security level and communication guidelines. Changes in the doctor-patient relationship and the impact of precision medicine on the quality of life should be further investigated. Additionally, the cost-effectiveness of precision medicine should be further examined, in order to avoid malinvestment. (shrink)

This article questions the commonly held view that professional ethics is grounded in general ethical principles, in particular, respect for client (or patient) autonomy and beneficence in the treatment of clients (or patients). Although these are admirable as general ethical principles, we argue that there is considerable logical difficulty in applying them to the professional-client relationship. The transition from general principles to professional ethics cannot be made because the intended conclusion applies differently to each of the parties involved, whereas (...) the premise is a general principle that applies equally to both parties. It is widely accepted that professionals are required to recognize that clients or patients possess rights to autonomy that are more than the general rights to personal autonomy accepted in ordinary social life, and that professionals are expected to display beneficence toward their clients that is more than the beneficence expected of anyone in ordinary social life. The comparative component of professional ethics is an intrinsic feature of the professional situation, and thus it cannot be bypassed in working out a proper professional ethics. Thus, we contend, the proper professional treatment of clients or patients has not been explained by appeal to general ethical principles. (shrink)

In his seminal work, Truth and Method, theGerman philosopher Hans-Georg Gadamer distinguishesbetween three types of what he calls the experience ofthe `Thou'. In this paper, Gadamer's analysis of thisexperience is explained in terms of his philosophicalhermeneutics and brought to bear upon thepatient-professional relationship. It is argued thatwhile Gadamer's analysis implies fruitful insights fora dialogical account of the patient-professionalinteraction, it harbours elements which are conduciveto paternalistic practice of medicine. The strongattribution of value to tradition and the respect forauthority emphasized in (...) his theory result in a lack ofsensitivity for individual self-determination which isneeded for a successful account of thepatient-professional relationship. (shrink)

To investigate the phenomenon of patient–physician mistrust in China, a qualitative study involving 107 physicians, nurses and health officials in Guangdong Province, southern China, was conducted through semi-structured interviews and focus groups. In this paper we report the key findings of the empirical study and argue for the essential role of medical professionalism in rebuilding patient-physician trust. Health professionals are trapped in a vicious circle of mistrust. Mistrust leads to increased levels of fear and self-protection by doctors which exacerbate difficulties (...) in communication; in turn, this increases physician workloads, adding to a strong sense of injustice and victimization. These factors produce poorer healthcare outcomes and increasingly discontented and angry patients, escalate conflicts and disputes, and result in negative media coverage, all these ultimately contributing to even greater levels of mistrust. The vicious circle indicates not only the crisis of patient-physician relationship but the crisis of medicine as a profession and institution. Underlying the circle is the inherent conflict of interest in the healthcare system by which health professionals and hospitals have become profit-driven. This institutional conflict of interest seriously compromises the fundamental principle of medical professionalism—the primacy of patient welfare—as well as the traditional Chinese ideal of “medicine as the art of humanity”. Patient trust can be restored through rectifying this institutional conflict of interest and promoting medical professionalism via a series of recommended practical measures. (shrink)

In interprofessional clinical teams, the patients have interpersonal relationships with several practitioners. The aim of this study was to explore patients’ and practitioners’ perceptions of how such relationships may contribute to promote the whole team’s respect for the patient’s autonomy, as interpersonal patient–provider relationships may contribute to enhance patient autonomy. Sixteen qualitative in-depth interviews were conducted with 12 informants, including patients, nurses, physiotherapists, and physicians from three rehabilitation teams. Data were analysed according to Grounded Theory procedures. The informants discussed interpersonal (...) relationships as an integral and significant part of the team work. The practitioners tried to adjust their professional approach to the patients’ genuine opinions and let patients decide the teams’ goals. Close relationships with patients could be important to accomplish this, particularly described by nurses and physiotherapists, who could facilitate the communication with the rest of the team. (shrink)

By considering the nature of the relationship between patient and healer, The Healing Bond explores the responsibilities of both, with a special emphasis on the therapeutic responsibility. The editors and contributors examine both orthodox and unorthodox forms of healing practice and apply a variety of professional and analytic perspectives to the medical profession as a whole. They look at specific areas of health such as midwifery, psychoanalysis, naturopathy, the relations between medicine and state, and the appeal of "quacks." Particular (...) issues of current concern are also discussed, including medical litigation, codes of ethics among complementary practitioners and cooperation between orthodox and complementary medicine practitioners. Contributors: Mary Douglas, Calliope Farsides, David Peters, Roy Porter, Richenda Power, Margaret Stacey, Robert Sumerling, and Gillian Vanhegan. (shrink)

In this paper I briefly summarize Pellegrino’s phenomenological analysis of the ethics of the physician–patient relationship. In delineating the essential elements of the healing relationship, Pellegrino demonstrates the necessity for health care professionals to understand the patient’s lived experience of illness. In considering the phenomenon of illness, I identify certain essential characteristics of illness-as-lived that provide a basis for developing a rigorous understanding of the patient’s experience. I note recent developments in the systematic delivery of health care that (...) make it difficult for health care professionals to realize Pellegrino’s ethical model of the role of healer. Such developments limit both the physician’s freedom to act on behalf of the patient without the constraint of third parties and the physician’s freedom to act in light of his or her own ethical or religious convictions. Given these difficulties, I note MacIntyre’s call for the development of moral communities, as an alternative to the prevailing culture, and share a first-hand example illustrating how intentional Christian community provides an alternative nurturing context that permits the full development of the healing relationship. (shrink)

In this essay, the author reflects on his development as a physician by recounting two patient narratives of patients he cared for as a third year medical student. In the process of telling these stories of sickness, the author also provides a window on medical practice in the 1980’s in an academic medicine center and how practices have changed. Decades before what has been dubbed “narrative medicine,” the author learned the power of words to shape relationships and promote professional formation.

Background An increasing number of studies on physicians’ professionalism have been done since the 2002 publication of Medical Professionalism in the New Millennium: A Physician Charter. The Charter proposed three fundamental principles and ten responsibilities. However, most studies were done in developed countries, and few have been done in China. Additionally, few studies have examined the effect of patient-centered hospital culture (PCHC) on physicians’ professionalism. We aimed to investigate physicians’ medical professionalism in public hospitals in China, and to assess mediating (...) effect of professional attitudes in the relationship of PCHC with professional behaviours. Methods Self-administered questionnaires including professional attitudes (20 items) and behaviours (10 items) survey and PCHC scale (22 items) were given to clinical physicians in five public hospitals, China. The mediating effect of professional attitudes in the relationship of PCHC with professional behaviours was tested. Result 232 valid questionnaires were collected. More than 90% (208) respondents agreed with 15 of 20 specific statements on medical professionalism. As for the responsibility of improving quality of care, 54 (23%) respondents disagreed with reporting of incompetent colleagues and as for the responsibility of maintaining professional competence, 49 (21%) disagreed with recertification. More than 185 (83%) respondents reported that they sometimes, usually, or always showed the four positive behaviours on the questionnaire, and 173 (77%) reported that they never showed the six negative behaviours. Mediating effect analysis revealed that two dimensions of PCHC (i.e. value/institution culture and behaviour/material culture) had a significant positive impact on physicians’ professional behaviour, and professional attitude played a complete mediation role between them, but another dimension of PCHC (i.e. negative evaluation of hospital) directly affected professional behaviour without influencing professional attitude. Conclusion Chinese physicians showed positive professional attitudes and behaviours. Different dimensions of PCHC affected physicians’ attitudes and behaviours in different ways. (shrink)

The purpose of this article is to examine whether patient/client autonomy is always compatible with the nurse’s role of advocacy. The author looks separately at the concepts of autonomy and advocacy, and considers them in relation to the reality of clinical practice from professional, ethical and legal perspectives. Considerable ambiguity is found regarding the legitimacy of claims of a unique function for nurses to act as patient advocates. To act as an advocate may put nurses at personal and professional risk. (...) It may also be deemed arrogant and insulting to other health care professionals. Patient autonomy can be seen as a subcategory of the right of every individual to self-determination, and as such is protected by law. However, it is questionable whether the traditionally paternalistic approach to health care provision truly respects the autonomous rights of each patient. The author considers examples and cases from the literature that resulted in professional and/or personal difficulties for the nurses involved, and also reflects on an incident from her own practice where a positive outcome was achieved that demonstrated compatibility between the concepts under consideration. (shrink)

The idea behind this article is to discuss the importance and to develop the concept of reciprocity in asymmetric professional relationships. As an empirical starting point for an examination of the possible forms of reciprocity between patients and nurses in psychiatry, we chose two qualitative in-depth interviews with two different patients. The manners in which these two patients relate to medical personnel—one is dependent, the other is independent—show that this presents challenges to nurses. The theoretical context is provided by the (...) notion of mature care as it has been developed by feminist-oriented ethics of care, in contrast to the notion of altruistic care. In relation to the concept of mature care, we discuss how nursing can be perceived in demanding relationships with patients in psychiatry. Reciprocity implies that, in principle, the interests of the nurses also matter in a nurse-patient relationship. We show that reciprocity—in practice—is complicated and challenging in a number of different ways. Mature care—with its systematic inclusion of relationships and reciprocity—provides an alternative understanding of what takes place between patients and nurses compared with an altruistic notion of care. As such, mature care can be regarded as an useful paradigm for nurse-patient relationships in psychiatry. (shrink)

Este artículo aborda la importancia de la comprensión del discurso en la relación médico-paciente. Su objetivo radica en valorar los múltiples condicionamientos que favorecen o entorpecen la comprensión en el proceso comunicativo que se produce entre el profesional de la salud y el enfermo. Se proporcionan, además, algunas sugerencias que el médico ha de tener en cuenta por ser quien conduce el intercambio con el paciente. This article deals with the importance of understanding doctor-patient's typical discourse. It values the several (...) conditionings that favor or hinder understanding during the communicative process between health professionals and patients. It also provides doctors with suggestions since they are in charge of leading doctor-patient interaction. (shrink)