This article critically questions the commercialization of hospice care and the ethical concerns associated with the industry's movement toward “market-driven medicine” at the end of life. For example, the article examines issues raised by an influx of for-profit hospice providers whose business model appears at its core to have an ethical conflict of interest between shareholders doing well and terminal patients dying well. Yet, empirical data analyzing the experience of patients across the hospice industry are limited, and general claims that (...) end-of-life patient care is inferior among for-profit providers or even that their business practices are somehow unseemly when compared to nonprofit providers cannot be substantiated. In fact, non-profit providers are not immune to potentially conflicting concerns regarding financial viability (i.e., “no margin, no mission”). Given the limitations of existing empirical data and contrasting ideological commitments of for-profit versus non-profit providers, the questions raised by this article highlight important areas for reflection and further study. Policymakers and regulators are cautioned to keep ethical concerns in the fore as an increasingly commercialized hospice industry continues to emerge as a dominant component of the U.S. health care system. Both practitioners and researchers are encouraged to expand their efforts to better understand how business practices and commercial interests may compromise the death process of the patient and patient's family — a process premised upon a philosophy and ethical tradition that earlier generations of hospice providers and proponents established as a trusted, end-of-life alternative. (shrink)

In our society, some aspects of life are off-limits to commerce. We prohibit the selling of children and the buying of wives, juries, and kidneys. Tainted blood is an inevitable consequence of paying blood donors; even sophisticated laboratory tests cannot supplant the gift-giving relationship as a safeguard of the purity of blood. Like blood, health care is too precious, intimate, and corruptible to entrust to the market.The hospice movement in the United States is approximately 40 years old. During these past (...) four decades, the concept of holistic, multidisciplinary care for patients who are suffering from a terminal illness has evolved from a modest, grassroots constellation of primarily volunteer-run and community-governed endeavors to a multimillion dollar industry where the surviving nonprofits compete with for-profit providers, often publicly traded, managed by M.B.A.-trained executives, and governed by corporate boards. The relatively recent emergence of for-profit hospice reflects an increasing commercialization of health care in the United States, the potentially adverse impact of which has been well documented. (shrink)

Financial ties between physicians and pharmaceutical companies are pervasive and controversial. However, little is known about how patients perceive such ties. This paper describes an experiment examining how a national sample of U.S. adults perceived a variety of financial relationships between physicians and drug companies. Each respondent read a single scenario about a hypothetical physician and his financial ties to the pharmaceutical industry; scenarios varied in terms of payment type of and amount. Respondents then evaluated the physician on several dimensions (...) . Findings revealed that perceptions of the physician were more strongly influenced by payment type than by payment amount. Specifically, respondents were quite critical of doctors who owned drug company stock or received industry payments for meals and lodging, but were more forgiving of physicians who received free drug samples or consulting fees . Interestingly, physicians who received no payments, while seen as honest, were also viewed by some respondents as inexperienced or uninformed about new treatments. Implications for public policy and future research are discussed. (shrink)

Financial relationships and business transactions between physicians and the health care industry are common. These relationships take a variety of forms, including payments to physicians in exchange for consulting services, reimbursement of physician travel expenses when attending medical device and pharmaceutical educational conferences, physician ownership in life science company stocks, and the provision of free drug samples. Such practices are not intrinsic to medical practice, but as the Institute of Medicine described in its 2009 report, these relationships have the potential (...) to produce positive collaborations that improve patient care and public health, and most physicians view it as “ethically proper to accept items ranging from drug samples to a lucrative consultantship.”However, financial relationships between physicians and pharmaceutical, medical device and biotechnology companies can also create negative influences on physician judgment that compromise patient care and jeopardize the public’s trust. (shrink)

"Thinking like a lawyer" is a phrase familiar to every law student, and the development of these analytical skills are, of course, essential. In this essay, however, I reflect on the value of a more expansive approach to professional formation. I argue that legal education best serves students, the bar, and the society when it takes seriously the importance of moral imagination, interpersonal relationships, and personal wellness.

The empirical literature exploring lawyers and their moral decision making is limited despite the “crisis” of unethical and unprofessional behavior in the bar that has been well documented for over a decade. In particular we are unaware of any empirical studies that investigate the moral landscape of the health lawyer’s practice. In an effort to address this gap in the literature, an interdisciplinary team of researchers at Vanderbilt University designed an empirical study to gather preliminary evidence regarding the moral reasoning (...) of health care attorneys. The primary research question was how health lawyers respond when they encounter ethical or moral dilemmas in their practice for which the law fails to offer a bright-line solution. In exploring this question, we sought to understand better what motivations or influences guide action when health lawyers confront ethical quandaries, and whether there are specific differences, e.g., gender, experience, or religiosity, that are associated with specific responses to situations testing ethical or moral boundaries. (shrink)

Writing in 1999, legal ethics scholar Brad Wendel noted that “[v]ery little empirical work has been done on the moral decision making of lawyers.” Indeed, since the mid-1990s, few empirical studies have attempted to explore how attorneys deliberate about ethical dilemmas they encounter in their practice. Moreover, while past research has explored some of the ethical issues confronting lawyers practicing in certain specific areas of practice, no published data exists probing the moral mind of health care lawyers. As signaled by (...) the creation of a regular column “devoted to ethical issues arising in the practice of health law” in the Journal of Law, Medicine & Ethics, the time to address the empirical gap in the professional ethics literature is now. Accordingly, this article presents data collected from 120 health care lawyers. Presenting this population with a number of hypothetical scenarios relating to how they would respond when confronting an ethical dilemma without an obvious solution or when facing a situation in which their personal values were in tension with their professional obligations, this article represents a first step toward better understanding how lawyers who practice in health care settings understand and resolve the moral discomfort they encounter in their professional lives. (shrink)

The authors reject arguments by Professor Joseph Fletcher (author of Situation Ethics) that in some circumstances parents may be held responsible for producing genetically defective offspring, but offer arguments of their own for the same conclusion. Their arguments could, they suggest, justify `wrongful life' claims by the genetically defective infant against the mother. While researching this paper both authors were postdoctoral fellows in medical ethics in the Program on Human Values and Ethics at the University of Tennessee Center for the (...) Health Sciences. (shrink)

The diffusion of technology in the US has taken place in an environment of both regulation and free enterprise. Each has been subject to manipulation by doctors and medical administrators that has fostered unprecedented ethical dilemmas and legal challenges. Understanding these developments and historical precedents may allow a more rational diffusion policy for medical technology in the future.

Five experiments provide evidence for a class of ‘dual character concepts.’ Dual character concepts characterize their members in terms of both (a) a set of concrete features and (b) the abstract values that these features serve to realize. As such, these concepts provide two bases for evaluating category members and two different criteria for category membership. Experiment 1 provides support for the notion that dual character concepts have two bases for evaluation. Experiments 2-4 explore the claim that dual character concepts (...) have two different criteria for category membership. The results show that when an object possesses the appropriate concrete features, but does not fulfill the appropriate abstract value, it is judged to be a category member in one sense but not in another. Finally, Experiment 5 uses the theory developed here to construct artificial dual character concepts and examines whether participants react to these artificial concepts in the same way as naturally occurring dual character concepts. The present studies serve to define the nature of dual character concepts and distinguish them from other types of concepts (e.g., natural kind concepts), which share some, but not all of the properties of dual character concepts. More broadly, these phenomena suggest a normative dimension in everyday conceptual representation. (shrink)

This paper examines the historical rise of both cardiopulmonary resuscitation and the do-not-resuscitate order and the wisdom of their continuing status in U.S. hospital practice and policy. The practice of universal presumed consent to CPR and the resulting DNR policy are the products of a particular time and were responses to particular problems. In order to keep the excesses of technology in check, the DNR policies emerged as a response to the in-hospital universal presumed consent to CPR. We live with (...) this historical concretion, which seems to perpetuate a false culture that the patient's wishes must be followed. The authors are critical of the current U.S. climate, where CPR and DNR are viewed as two among a panoply of patient choices, and point to UK practice as an alternative. They conclude that physicians in the United States should radically rethink approaches to CPR and DNR. (shrink)

While studies on the characteristics of flow states and their relation to peak performance exist, little is known about the dynamics by which flow states emerge and develop over time. The current paper qualitatively explores the necessary pre-conditions to enter flow, and the development of flow over time until its termination. Using an elicitation interview, participants were asked to recall their flow experiences in sports or music performances. The analysis resulted in the identification of the following three phases that athletes (...) and musicians experience during flow: Preparation to enter flow; Entry into the flow state and; Exit from the flow state. These three phases are characterized by several sub-themes contributing to the experience of flow. The function of emotions is crucial, as they play a core role across all three phases and regulate flow over time. The findings provide insights into the phenomenological characteristics of the transition and maintenance of the three proposed phases and the temporal dynamics of flow. (shrink)

Over the past several decades, psychological essentialism has been an important topic of study, incorporating research from multiple areas of psychology, philosophy and linguistics. At its most basic level, essentialism is the tendency to represent certain concepts in terms of a deeper, unobservable property that is responsible for category membership. Originally, this concept was used to understand people’s reasoning about natural kind concepts, such as TIGER and WATER, but more recently, researchers have identified the emergence of essentialist-like intuitions in a (...) number of other contexts, including people’s representation of concepts like SCIENTIST or CHRISTIAN. This paper develops an account that aims to capture how essentialism may operate across these varied cases. In short, we argue that while there is diversity in the forms essentialism can take, these varied cases reflect the same underlying cognitive structure. (shrink)

In this paper, I offer an understanding of G.E. Moore’s epistemology as presented in, “A Defence of Common Sense” and “Proof of an External World”. To frame the discussion, I look to Roderick Chisholm’s essay, The Problem of the Criterion. I begin by looking at two ways that Chisholm believes one can respond to the problem of the criterion, and, referring back to Moore’s essays, explain why it is not unreasonable for Chisholm to believe that he is following a line (...) of reasoning that Moore might take. I then show why I believe Chisholm is actually trying to do something quite different from what Moore was, and thus misses Moore’s actual point. I conclude that Moore is best understood as rejecting traditional epistemological concerns. By forcing Moore to deal with a traditional epistemological problem, it will become clear how bold Moore’s “epistemology” is. (shrink)

Past research has identified a number of asymmetries based on moral judgments. Beliefs about what a person values, whether a person is happy, whether a person has shown weakness of will, and whether a person deserves praise or blame seem to depend critically on whether participants themselves find the agent's behavior to be morally good or bad. To date, however, the origins of these asymmetries remain unknown. The present studies examine whether beliefs about an agent's “true self” explain these observed (...) asymmetries based on moral judgment. Using the identical materials from previous studies in this area, a series of five experiments indicate that people show a general tendency to conclude that deep inside every individual there is a “true self” calling him or her to behave in ways that are morally virtuous. In turn, this belief causes people to hold different intuitions about what the agent values, whether the agent is happy, whether he or she has shown weakness of will, and whether he or she deserves praise or blame. These results not only help to answer important questions about how people attribute various mental states to others; they also contribute to important theoretical debates regarding how moral values may shape our beliefs about phenomena that, on the surface, appear to be decidedly non-moral in nature. (shrink)

BackgroundThe U.S. Food and Drug Administration traditionally has kept confidential significant amounts of information relevant to the approval or non-approval of specific drugs, devices, and biologics and about the regulatory status of such medical products in FDA’s pipeline.ObjectiveTo develop practical recommendations for FDA to improve its transparency to the public that FDA could implement by rulemaking or other regulatory processes without further congressional authorization. These recommendations would build on the work of FDA’s Transparency Task Force in 2010.MethodsIn 2016-2017, we convened (...) a team of academic faculty from Harvard Medical School, Brigham and Women’s Hospital, Yale Medical School, Yale Law School, and Johns Hopkins Bloomberg School of Public Health to develop recommendations through an iterative process of reviewing FDA’s practices, considering the legal and policy constraints on FDA in expanding transparency, and obtaining insights from independent observers of FDA.ResultsThe team developed 18 specific recommendations for improving FDA’s transparency to the public. FDA could adopt all these recommendations without further congressional action.FundingThe development of the Blueprint for Transparency at the U.S. Food and Drug Administration was funded by the Laura and John Arnold Foundation. (shrink)

The Twin Earth thought experiment invites us to consider a liquid that has all of the superficial properties associated with water (clear, potable, etc.) but has entirely different deeper causal properties (composed of “XYZ” rather than of H2O). Debates about natural kind concepts have sought to accommodate an apparent fact about ordinary people's judgments: Intuitively, the Twin Earth liquid is not water. We present results showing that people do not have this intuition. Instead, people tend to judge that there is (...) a sense in which the liquid is not water but also a sense in which it is water. (shrink)

This paper examines the historical rise of both cardiopulmonary resuscitation and the do-not-resuscitate order and the wisdom of their continuing status in U.S. hospital practice and policy. The practice of universal presumed consent to CPR and the resulting DNR policy are the products of a particular time and were responses to particular problems. In order to keep the excesses of technology in check, the DNR policies emerged as a response to the in-hospital universal presumed consent to CPR. We live with (...) this historical concretion, which seems to perpetuate a false culture that the patient's wishes must be followed. The authors are critical of the current U.S. climate, where CPR and DNR are viewed as two among a panoply of patient choices, and point to UK practice as an alternative. They conclude that physicians in the United States should radically rethink approaches to CPR and DNR. (shrink)

Do professional ethicists behave any morally better than other professors do? Do they show any greater consistency between their normative attitudes and their behavior? In response to a survey question, a large majority of professors (83 percent of ethicists, 83 percent of nonethicist philosophers, and 85 percent of nonphilosophers) expressed the view that “not consistently responding to student e-mails” is morally bad. A similarly large majority of professors claimed to respond to at least 95 percent of student e-mails. These professors, (...) and others, were sent three e-mails designed to look like queries from students. Ethicists’ e-mail response rates were not significantly different from the other two groups’. Expressed normative view correlated with self-estimated rate of e-mail responsiveness, especially among the ethicists. Empirically measured e-mail responsiveness, however, was at best weakly correlated with self-estimated e-mail responsiveness; and professors’ expressed normative attitude was not significantly correlated with empirically measured e-mail responsiveness for any of the three groups. (shrink)