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)

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)

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)

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.

Alasdair MacIntyre described the late modern West as driven by two moral values: efficiency and effectiveness. Regardless of whether you accept MacIntyre's overarching story, it seems clear that efficiency and effectiveness have achieved a zenith in institutional health care structures, such that these two aspects of care become the final arbiters of what counts as “good” care. At the very least, they are dominant in many clinical contexts and act as the interpretative lens for the judgments of successful health care (...) managers. The drive of efficiency can also be seen in “lean” management methods (originally imported from the automotive manufacturing industry) increasingly deployed in the intensive care unit. This drive gives us pause. The high stress of the ICU is exacerbated by the enormous complexity of technological interventions designed to maintain physiological functioning as the body heals, as well as the ever‐present concerns related to cost, effectiveness, and efficiency. The ICU, therefore, provides an illustrative view of the challenges facing clinicians, as well as resource managers, in terms of delivering care. In short, the goal of technocratic efficiency often ends up at odds with humane purposes. To better understand these contemporary health care dynamics, we conducted a limited series of focus group discussions and interviews with residents experienced in the challenges of delivering care in the ICU environment. In what follows, we highlight some narrative observations drawn from these focus groups. We found a recurrent and disconcerting refrain among our informants that has not been adequately described or addressed in the literature: technocratic management techniques have crept into and bifurcated clinical care strategies in the ICU. Specifically, we highlight the influence of concerns around efficiency and effectiveness and the ways in which these foci have contributed to a bifurcation in care in the ICU along two trajectories: either compassionate care or curative care. (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)

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 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)