Professionalism requires that physicians uphold the best interests of patients while simultaneously insuring just use of health care resources. Current articulations of these obligations like the American Board of Internal Medicine Foundation's Physician Charter do not reconcile how these obligations fit together when they conflict. This is the problem of dual agency. The most common ways of dealing with dual agency: “bunkering”—physicians act as though societal cost issues are not their problem; “bailing”—physicians assume that they are merely agents of society (...) and deliver care typically based on a strongly consequentialist public health ethic; or “balancing”—a vaguely specified attempt to uphold both patient welfare and societal need for judicious resource use simultaneously—all fail. Here I propose how the problem of dual agency might begin to be addressed with rigor and consistency. Without dealing with the dual agency problem and getting more specific about how to reconcile its norms when they conflict, the expectations of professionalism risk being written off as cute, nonbinding aphorisms from the medical profession. (shrink)

Principlism is simple. Four intuitive ideas, creating order out of moral chaos, at least categorizing considerations for better deliberation over right and wrong, good and bad, in a modern, plurali...

It was the spring of 2020 when the email came to our inboxes—a memo from our Institutional Review Board informing us that we were approved to begin conducting our pragmatic clinical trial with a wa...

Volume 20, Issue 4, May 2020, Page 76-78.

A traditional ethic of medicine asserts that physicians have special obligations to individual patients with whom they have a clinical relationship. Contemporary trends in US healthcare financing like bundled payments seem to threaten traditional conceptions of special obligations of individual physicians to individual patients because their population-based focus sets a tone that seems to emphasise responsibilities for groups of patients by groups of physicians in an organisation. Prior to undertaking a cogent debate about the fate and normative weight of special (...) obligations and a traditional ethic for contemporary healthcare, we need a deeper examination of what the traditional ethic of special obligations really means. Here we offer a conception of ‘doubly distributed’ special obligations. Physicians and similarly minded healing professionals abiding by a traditional ethic have always spread their devotion and attention across multiple patients and have shared responsibilities with physician and non-physician colleagues in much the same way devoted parents have frequently distributed their special obligations across multiple children and across multiple parents. By taking up the extended analogy of parent we argue that doubly distributing special obligations need not contradict the possibility of special obligations in restructured collective forms of healthcare delivery and financing. (shrink)

Important discussions about limiting care based on professional judgment often devolve into heated debates over the place of physicians in bedside rationing. Politics, loaded rhetoric, and ideological caricature from both sides of the rationing debate obscure precise points of disagreement and consensus, and hinder critical dialogue around the obligations and boundaries of professional practice. We propose a way forward by reframing the rationing conversation, distinguishing between the scale of the decision and its context avoiding the word “rationing.” We propose to (...) shift the terminology, using specific, descriptive words to defuse conflict and re-focus the debate towards substantive issues. These distinctions can clarify the real ethical differences at stake and facilitate a more constructive conversation about the clinical and social responsibilities of physicians to use resources ethically at the bedside and their role in allocating medical resources at a societal level. (shrink)

Important discussions about limiting care based on professional judgment often devolve into heated debates over the place of physicians in bedside rationing. Politics, loaded rhetoric, and ideological caricature from both sides of the rationing debate obscure precise points of disagreement and consensus, and hinder critical dialogue around the obligations and boundaries of professional practice. We propose a way forward by reframing the rationing conversation, distinguishing between the scale of the decision and its context avoiding the word “rationing.” We propose to (...) shift the terminology, using specific, descriptive words to defuse conflict and re-focus the debate towards substantive issues. These distinctions can clarify the real ethical differences at stake and facilitate a more constructive conversation about the clinical and social responsibilities of physicians to use resources ethically at the bedside and their role in allocating medical resources at a societal level. (shrink)

A traditional ethic of medicine asserts that physicians have special obligations to individual patients with whom they have a clinical relationship. Contemporary trends in US healthcare financing like bundled payments seem to threaten traditional conceptions of special obligations of individual physicians to individual patients because their population-based focus sets a tone that seems to emphasise responsibilities for groups of patients by groups of physicians in an organisation. Prior to undertaking a cogent debate about the fate and normative weight of special (...) obligations and a traditional ethic for contemporary healthcare, we need a deeper examination of what the traditional ethic of special obligations really means. Here we offer a conception of ‘doubly distributed’ special obligations. Physicians and similarly minded healing professionals abiding by a traditional ethic have always spread their devotion and attention across multiple patients and have shared responsibilities with physician and non-physician colleagues in much the same way devoted parents have frequently distributed their special obligations across multiple children and across multiple parents. By taking up the extended analogy of parent we argue that doubly distributing special obligations need not contradict the possibility of special obligations in restructured collective forms of healthcare delivery and financing. (shrink)

We agree with Lynch et al. that patients with chronic diseases and Band-Aid treatments are unlikely to benefit from a version of Operation Warp Speed or by deprioritizing standards of scientific ev...

Volume 20, Issue 9, September 2020, Page 26-28.

How does one committed to the claims of Christ and a biblical story of redemption live Christianly and navigate the competing worldviews encountered in everyday medical practice? Adopting the practical conceptual framework promoted by Reformed Christian philosopher and theologian Albert Wolters, we argue for an all-encompassing biblical understanding of God’s cosmic redemption plan for the entire creation order in contrast to a more typical sacred/secular duality. We then apply the concepts of structure and direction, drawn from a pretheological understanding of (...) human life drawn from the Scripture, to a semi-fictional case study in discerning Christian faithfulness in everyday mundane aspects of medicine. Our subsequent analysis seeks to render an interpretation of what it means to live life consistent with that worldview when confronted with challenges like those presented in the case. (shrink)

Obtaining informed consent is a cornerstone of biomedical research, yet participants comprehension of presented information is often low. The most effective interventions to improve understanding rates have not been identified.

Moral pluralism is the norm in contemporary society. Even the best philosophical arguments rarely persuade moral opponents who differ at a foundational level. This has been vividly illustrated in contemporary debates in bioethics surrounding contentious issues such as abortion and euthanasia. It is readily apparent that bioethics discourse lacks an empirical explanation for the broad differences about various topics in bioethics and health policy. In recent years, social and cognitive psychology has generated novel approaches for defining basic differences in moral (...) intuitions generally. We propose that if empirical research using social intuitionist theory explains why people disagree with one another over moral issues, then the results of such research might help people debate their moral differences in a more constructive and civil manner. We illustrate the utility of social intuitionism with data from a national physician survey. (shrink)

Teaching ethics is crucial to health sciences education. Doing it well requires a willingness to engage contentious social issues. Those issues introduce conflict and risk, but avoiding them ignores moral diversity and renders the work of ethics education irrelevant. Therefore, when (not if) contentious issues and moral differences arise, they must be acknowledged and can be addressed with humility, collegiality, and openness to support learning. Faculty must risk moments when not everyone will “feel safe,” so the candor implied in psychological (...) safety can emerge. The deliberative and social work of ethics education involves generous listening, wading into difference, and wondering together if our beliefs and arguments are as sound as we once thought. By forecasting the need for candid engagement with contentious issues and moral difference, establishing ground rules, and bolstering due process structures for faculty and students, a riskier and more relevant ethics pedagogy can emerge. Doing so will prepare everyone for the moral diversity they can expect in our common life and in practice. (shrink)

Purpose: to characterize ethics course content, structure, resources, pedagogic methods, and opinions among academic administrators and course directors at U.S. medical schools. Method: An online questionnaire addressed to academic deans and ethics course directors identified by medical school websites was emailed to 157 Association of American Medical Colleges member medical schools in two successive waves in early 2022. Descriptive statistics were utilized to summarize responses. Results: Representatives from 61 (39%) schools responded. Thirty-two (52%) respondents were course directors; 26 (43%) were (...) deans of academic affairs, medical education, or curriculum; and 3 with other roles also completed the survey (5%). All 61 schools reported some form of formal ethics education during the first year of medical school, with most (n = 54, 89%) reporting a formal mandatory introductory course during preclinical education. Schools primarily utilized lecture and small-group teaching methods. Knowledge-based examinations, attendance, and participation were most commonly used for assessment. A large majority regarded ethics as equally or more important than other foundational courses, but fewer (n = 37, 60%) provided faculty training for teaching ethics. Conclusions: Despite a response rate of 39 percent, the authors conclude that medical schools include ethics in their curricula in small-group and lecture formats with heterogeneity regarding content taught. Preclinical curricular redesigns must innovate and implement best practices for ensuring sound delivery of ethics content in future curricula. Additional large-scale research is necessary to determine said best practices. (shrink)

Physicians vary in their moral judgments about health care costs. Social intuitionism posits that moral judgments arise from gut instincts, called “moral foundations.” The objective of this study was to determine if “harm” and “fairness” intuitions can explain physicians’ judgments about cost-containment in U.S. health care and using cost-effectiveness data in practice, as well as the relative importance of those intuitions compared to “purity”, “authority” and “ingroup” in cost-related judgments.

We reflect on Dr. Iserson’s article in this journal, in which he suggests that clinicians must “shove” patients towards appropriate care. While recognizing that overt clinical guidance is part of care, we suggest that its use should be tempered by the guidance’s responsiveness to the human and emotional experience of each patient.

In the detailed, cogent, and well‐referenced Rationing Is Not a Four‐Letter Word: Setting Limits on Healthcare, Phillip Rosoff takes up an emotion‐laden entrenched argument as challenging as iPhone purchasing for teens—trying to convince a skeptical public and medical profession that “rationing” is just fine. According to Rosoff, despite its near expletive status, the “R word”—the much‐maligned third rail of American health policy‐is an inevitable and sensible choice for the future of health care in the United States. It is—rather like the (...) iPhone 4S—good enough, much cheaper, and really not that bad. (shrink)