*The views expressed are the author's own. This article should not be construed as representing policies of the American Medical Association.

BackgroundIn Pakistan, drug promotion practices, ethical or unethical, have rarely been in the spotlight. We aimed to assess the perception and barriers of medical representatives (MRs) and doctors (MDs) regarding ethical promotion of pharmaceuticals in Pakistan.MethodsA cross sectional survey was conducted in seven major cities of Pakistan for 6-months period. Self-administered questionnaire was used for data collection. Logistic regression and five-point Likert scale scoring was used to estimate the perceptions and barriers.ResultsCompared to national companies (NCs), the medical (...) representatives (MRs) of multinational companies (MNCs) strongly believed that their companies follow World Health Organization (WHO) (OR; 5.31, p = 0.0005), International Federation of Pharmaceutical Manufacturers & Associations (IFPMA) (OR; 6.45, p = 0.0005) and national codes of ethics (OR; 5.84, p = 0.0005). MNCs trained their MRs (OR; 6.68, p = 0.0005), provide accurate and valid scientific data (OR; 4.01, p = 0.007) with adequate system of accountability and controls on product samples (OR; 1.96, p = 0.047), while, NCs sponsor social or entertainment activities, seminars and conferences, and all sort of facilitation in form of gifts of their choice and clinic renovation for medical doctors (MDs). MDs perceptions were similar to MRs mentioned above, yet strongly agreed that companies offer cash payments or equivalents to MDs. The MRs of NCs/mncs and MDs agreed/strongly agreed that no external accountability, profiteering, pressure on sale targets, job insecurity, condoning unethical promotion by high-ups’ and business promotion by junior MDs were the predominant barriers.ConclusionIn conclusion, MRs of MNCs and MDs believed that MNCs follow certain codes of ethics in the promotion of pharmaceuticals, while NCs tend to be more profit oriented and even condone unethical promotion. All stakeholders, MRs, MDs and companies, might pose certain barriers, intentionally or unintentionally, in ethical promotion. (shrink)

This paper examines the role of modality resources (e.g., “may”, “often”) in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in representing behavioral pathology focusing, in particular, on Attention Deficit Hyperactivity Disorder (ADHD). ADHD diagnosis requires reports of non-practitioners (e.g., carers and teachers); an effective understanding of behavioral descriptors by the lay community is thus of paramount importance. The study combines qualitative linguistic discourse analysis and a corpus approach to study the presence and functions of modality, adopting a Systemic (...) Functional perspective towards language. The study argues that in the DSM-5 modality is an important linguistic resource for conveying clinical significance, inferred from graduations of recurrence and probability. However, adopting features of professional discourse in representing behavioral pathology for non-experts, especially when those resources are inherently evaluative, stresses the need of health literacy among the lay social community and accessibility in health communication materials, particularly when non-practitioners are involved in the diagnosis practice. (shrink)

In a collaborative work situation at a distance, the use of avatars to represent collaborators reduces collaborative effort. Also, animated avatars can help distant users to ground their relationship and facilitate their interaction because they materialise visual clues for the distant collaborators and their current activity. To check the validity of these hypotheses we set up an experiment based on the use of a collaborative virtual environment (CVE) synchronised for collective medical decision-making. Several teams of practitioners from different disciplines (...) will be required to deal with liver tumours displayed in Argonaute 3D. In this paper, we provide some evidence from existing studies for the hypotheses and select several measures to estimate the grounding process in CVEs. Next, we briefly describe the setup used to collect observable data with Argonaute 3D and we summarise first observations acquired with practitioners. (shrink)

The development and deployment of medical devices, along with most areas of healthcare, has been significantly impacted by the COVID-19 pandemic. This has had variable ethical implications, two of which we will focus on here. First, medical device regulations have been rapidly amended to expedite approvals of devices ranging from face masks to ventilators. Although some regulators have issued cessation dates, there is inadequate discussion of triggers for exiting these crisis standards, and evidence that this may not be (...) feasible. Given the relatively low evidence standards currently required for regulatory approval of devices, this further indefinite reduction in standards raises serious ethical issues. Second, the pandemic has disrupted the usual operations of device representatives in hospitals, providing an opportunity to examine and refine this potentially ethically problematic practice. In this paper we explain and critically analyse the ethical implications of these two pandemic-related impacts on medical devices and propose suggestions for their management. These include an endpoint for pandemic-related adjustments to device regulation or a mechanism for continued refinement over time, together with a review of device research conducted under crisis conditions, support for the removal and replacement of emergency approved devices, and a review of device representative credentialling. (shrink)

Relationships between physicians and pharmaceutical sales representatives (PSRs) often create conflicts of interest, not least because of the various benefits received by physicians. Many countries attempt to control pharmaceutical industry marketing strategies through legal regulation, and this is true in Poland where efforts are underway to eliminate any practices that might be considered corrupt in medicine. The present research considered Polish medical students’ opinions about domestic laws restricting doctors’ acceptance of expensive gifts from the industry, the idea of (...) compulsory transparency, and the possibility of introducing a Polish Sunshine Law. A qualitative, focus group-based, interview method was used. Data were gathered from nine focus groups involving 92 medical students from three universities located in major Polish cities. The article presents a classification of opposing student views with regard to the consequences of introducing different legal solutions; this should be useful for policy makers deliberating on how to optimally regulate pharmaceutical marketing. The study’s results are discussed in the context of the public bioethical debate in Poland. (shrink)

Intuition is frequently used in medicine. Along with the use of existing medical rules, there is a separate channel that physicians rely on when making decisions: their intuition. To cope with the epistemic problem of using intuition, I use some clues from Wittgenstein's philosophy to illuminate the decision-making process in medicine. First, I point to a connection between intuition as functioning in medicine and Wittgenstein's notions of "seeing as" or noticing "aspects". Secondly, I use Wittgenstein notion of empirical regularities (...) hardened into rules to suggest that there are two stages that should be addressed in the analysis of medical practice: the first concerns the accumulation of cases and the second pertains to the setting a rule based on these cases. I argue further that the medical context is exceptional in that the two stages are intertwined and, and explain the consequences of this fact for the physician's work. Finally, inspired by Wittgenstein's rule-following conundrum, I argue that medicine is particularly prone to difficulties in applying a general rule to a specific case represented by an individual patient. Recourse to intuition is reflects the physicians' efforts to bridge this gap. (shrink)

This book, written both for a Canadian and an international readership, provides a multidisciplinary review of the framework and performance of the Canadian Medical Assistance in Dying (MAID) program. In the first five years (2015-2021) of operation, this program delivered voluntary euthanasia and assistance in suicide to over 30,000 Canadian residents, presently representing a 30% annual growth. Looking back on these first five years, the 30 Canadian scholars and clinicians contributing to this volume raise important issues and attempt to (...) answer key questions that have arisen in regards to its operation and its stated objectives. This volume strikes the most appropriate balance between the autonomy of persons who seek medical assistance, versus the interests and protection of vulnerable persons. Finally, the book makes suggestions on how the program can presently be improved. It identifies gaps in knowledge about MAID’s operational program and its impact on individuals, families and society in order to stimulate the necessary research that is essential to the evolution of a healthy and well-balanced program. As a first, comprehensive examination of medically assisted deaths in Canada, this publication will be of great value to lay, professional, academic, political audiences both domestically and internationally, especially in jurisdictions that are examining their options of permitting assisted deaths. (shrink)

: The Islamic jurists utilized the discipline of maqāṣid al-sharīʿah,in its capacity as the philosophy of Islamic law, in their legal and ethicalinterpretations, with added interest in addressing the issues of modern times.Aphoristically subsuming the major themes of the Sharīʿah, maqāṣid play apivotal role in the domain of decision-making and deduction of rulings onunprecedented ethical discourses. Ethics represent the infrastructure of Islamiclaw and the whole science of Islamic jurisprudence operates in the lightof maqāṣid to realize the ethics in people’s lives. (...) Scrutinizing the key themesof maqāṣid-based ijtihād and scope of ethics in maqāṣid, this article delvesinto the discourse on the application of maqāṣid to medical ethics. As a casestudy, this research analyses the extent of medical confidentiality in the light ofmaqāṣid and arrives at the conclusion that limited confidentiality goes more inline with the maxims of maqāṣid. (shrink)

Within bioethics, two prevailing approaches structure how we think about the role of medical surrogates and the decisions that they must make on behalf of incompetent patients. One approach views the surrogate primarily as the patient's agent, obediently enacting the patient's predetermined will. The second approach views the surrogate as the patient's custodian, judging for herself how to best safeguard the patient's interests. This paper argues that both of these approaches idealize away some of the ethically relevant features of (...) advance care planning that make patient preferences so inscrutable and surrogate decision-making so burdensome. It proposes a new approach to surrogate decision-making, the Fiduciary Agency Approach. On this novel approach, the surrogate has authority to not only act on the patient's behalf as the patient's agent but also to decide on the patient's behalf as the patient's fiduciary. One upshot of this new approach is that surrogates must sometimes go against the expressed dictates of the patients' advance directives not necessarily because doing so would be in the patient's best interest but rather because doing so would best represent the patients' will. (shrink)

Egg freezing has led to heated debates in healthcare policy and bioethics. A crucial issue in this context concerns the distinction between “medical” and “social” egg freezing —contrasting objections to bio-medicalization with claims for oversimplification. Yet such categorization remains a criterion for regulation. This paper aims to explore the “regulatory boundary-work” around the “medical”–”social” distinction in different egg freezing regulations. Based on systematic documents’ analysis we present a cross-national comparison of the way the “medical”–”social” differentiation finds expression (...) in regulatory frameworks in Austria, Germany, Israel, and the Netherlands. Findings are organized along two emerging themes: the definition of MEF and its distinctiveness—highlighting regulatory differences in the clarity of the definition and in the medical indications used for creating it ; and hierarchy of medical over social motivations reflected in usage and funding regulations. Blurred demarcation lines between “medical” and “social” are further discussed as representing a paradoxical inclusion of SEF while offering new insights into the complexity and normativity of this distinction. Finally, we draw conclusions for policymaking and the bioethical debate, also concerning the related cryopolitical aspects. (shrink)

Simulations are used in very different contexts and for very different purposes. An emerging development is the possibility of using simulations to obtain a more or less representative reproduction of organs or even entire persons. Such simulations are framed and discussed using the term ‘digital twin’. This paper unpacks and scrutinises the current use of such digital twins in medicine and the ideas embedded in this practice. First, the paper maps the different types of digital twins. A special focus is (...) put on the concrete challenges inherent in the interactions between persons and their digital twin. Second, the paper addresses the questions of how far a digital twin can represent a person and what the consequences of this may be. Against the background of these two analytical steps, the paper defines first conditions for digital twins to take on an ethically justifiable form of representation. (shrink)

Despite concerns about the relationships between health professionals and the medical device industry, the issue has received relatively little attention. Prevalence data are lacking; however, qualitative and survey research suggest device industry representatives, who are commonly present in clinical settings, play a key role in these relationships. Representatives, who are technical product specialists and not necessarily medically trained, may attend surgeries on a daily basis and be available to health professionals 24 hours a day, 7 days a (...) week, to provide advice. However, device representatives have a dual role: functioning as commissioned sales representatives at the same time as providing advice on approaches to treatment. This duality raises the concern that clinical decision-making may be unduly influenced by commercial imperatives. In this paper, we identify three key ethical concerns raised by the relationship between device representatives and health professionals: impacts on healthcare costs, the outsourcing of expertise and issues of accountability and informed consent. These ethical concerns can be addressed in part through clarifying the boundary between the support and sales aspects of the roles of device representatives and developing clear guidelines for device representatives providing support in clinical spaces. We suggest several policy options including hospital provision of expert support, formalising clinician conduct to eschew receipt of meals and payments from industry and establishing device registries. (shrink)

This paper reviews the research done in Finland on medical ethics in the last three years and published in four leading journals. The general characteristics of this area are discussed and some comments on its most conspicuous representatives are offered. The conclusion reached is that medical ethics in Finland is still in a rather embryonic stage of development, and that more systematic and theoretically sophisticated approaches are required. However, since many physicians have become interested in ethical questions, (...) it can be reasonably assumed that a more lively and theoretically grounded discussion will ensue in the near future. (shrink)

Travelling internationally to acquire medical treatments otherwise unavailable or inaccessible in one’s home country is not a novel concept. Conventionally, such medical travel largely entailed patients from developed countries or wealthy patients from the developing world seeking care in Western facilities like the Mayo Clinic in the U.S. and myriad private clinics along Harley Street in London, England. What is different about the topical phenomenon known as “medical tourism” is the growing trend of health services export in (...) the opposite direction. The number of patients travelling from the developed world to low- and middle-income countries for treatments has ballooned in recent years, primarily driven by difficulties with accessing affordable care at home. According to a liberal estimate by the Deloitte Center for Health Solutions, the number of Americans travelling abroad for care rose from 750,000 in 2007 to 1.6 million in 2012. On the flip side, Thailand reportedly treated a total of 1.3 million foreign nationals in 2007, which represented a 16% leap from 2001. (shrink)

BackgroundBurnout is being experienced by medical students, residents, and practicing physicians at significant rates. Higher levels of Hardiness and Emotional Intelligence may protect individuals against burnout symptoms. Previous studies have shown both Hardiness and Emotional IntelIigence protect against detrimental effects of stress and can be adapted through training; however, there is limited research on how training programs affect both simultaneously. Therefore, the objective of this study was to define the association of Hardiness and Emotional Intelligence and their potential improvement (...) through hyper realistic immersion simulation training in military medical students.MethodsParticipants in this study consisted of 68 second year medical students representing five medical schools who were concurrently enrolled in the United States military scholarship program. During a six day hyper-realistic surgical simulation training course, students rotated through different roles of a medical team and responded to several mass-casualty scenarios. Hardiness and Emotional Intelligence were assessed using the Hardiness Resilience Gauge (HRG) and the Emotional Quotient Inventory (EQ-I 2.0) respectively, at two time points: on arrival (pre-event) and after completion of the course (post-event).ResultsHardiness and Emotional Intelligence scores and sub scores consistently improved from pre-event to post-event assessments. No difference in training benefit was observed between genders but differences were observed by age where age was more often associated with Emotional Intelligence. In addition, factor analysis indicated that the HRG and EQ-I 2.0 assessment tools measured predominately different traits although they share some commonalities in some components.ConclusionThis study indicates that Hardiness and Emotional Intelligence scores can be improved through immersion training in military medical students. Results from this study support the use of training course interventions and prompt the need for long term evaluation of improvement strategies on mitigating burnout symptoms. (shrink)

Authoritarian governments are characterised by political systems with concentrated and centralised power. Healthcare is a critical component of any state. Given the powers of an authoritarian regime, we consider the opportunities they possess to derive good health outcomes. The 2019 Varsity Medical Ethics Debate convened on the motion: ‘This house believes authoritarian government is the route to good health outcomes’ with Oxford as the Proposition and Cambridge as the Opposition. This article summarises and extends key arguments made during the (...) 11th annual debate between medical students from the Universities of Oxford and Cambridge. By contrasting the principles underlying authoritarianism and democracy, it enables a discussion into how they translate into healthcare provision and the outcomes derived. Based on the foundation of said principles, an exploration of select cases represents examples of applications and the results. We analyse the past, present and future implications on the basis of fundamental patient-centred care. (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)

With a global commitment to scaling up AIDS care and treatment in resource-poor settings for some of the most HIV-affected countries in Africa, availability of antiretroviral treatment is no longer the principal obstacle to expanding access to treatment. A shortage of trained healthcare personnel to initiate treatment and manage patients represents a more challenging barrier to offering life-saving treatment to all patients in need. Physician-centered treatment policies accentuate this challenge. Despite evidence that task shifting for nurse-centered AIDS patient care is (...) effective and can alleviate severe physician shortages that currently obstruct treatment scale-up, political commitment and policy action to support task shifting models of care has been slow to absent. In this paper we review the evidence in support of task shifting for AIDS treatment in Africa and argue that continued policy inaction amounts to unwarranted healthcare rationing and as such is ethically untenable. (shrink)

Vesicovaginal fistula was a catastrophic complication of childbirth among 19th century American women. The first consistently successful operation for this condition was developed by Dr J Marion Sims, an Alabama surgeon who carried out a series of experimental operations on black slave women between 1845 and 1849. Numerous modern authors have attacked Sims’s medical ethics, arguing that he manipulated the institution of slavery to perform ethically unacceptable human experiments on powerless, unconsenting women. This article reviews these allegations using primary (...) historical source material and concludes that the charges that have been made against Sims are largely without merit. Sims’s modern critics have discounted the enormous suffering experienced by fistula victims, have ignored the controversies that surrounded the introduction of anaesthesia into surgical practice in the middle of the 19th century, and have consistently misrepresented the historical record in their attacks on Sims. Although enslaved African American women certainly represented a “vulnerable population” in the 19th century American South, the evidence suggests that Sims’s original patients were willing participants in his surgical attempts to cure their affliction—a condition for which no other viable therapy existed at that time. (shrink)

In one common type of hybrid war states intervene on behalf of insurgents who represent a repressed identity group, but without ‘putting boots on the ground’. Such cases may be regarded as hybrids which contain elements of both ‘old’ and ‘new wars’. In ‘old wars’ victory in combat is sought and non-combatants do not need to be targeted. ‘New wars’ are identity conflicts in which civilians on the opposing side themselves become the hated objects of attack. This poses problems for (...) an intervening state which would not wish to tolerate such behaviour. One question to ask is whether the state owes the insurgents medical assistance if they require it. While they have a prima facie claim as combatants, their bad behaviour, it is argued, leads them to forfeit it. In ‘old wars’ civilians expect those fighting on their behalf to avoid attacks on enemy non-combatants, and states will wish insurgents to do likewise. Were military medics to treat insurgents who breach the laws of armed conflict and return them to service and probable re-offending they would arguably be accomplices. Medics should not be placed in this position for their role is not only ‘to conserve the fighting strength’ and to mitigate the horrors of war but also to facilitate its being fought justly. For, were they not to be deployed to treat wounded civilians and prisoners when possible, more suffering would ensue than necessity required, contrary to the cardinal principle of jus in bello. But similarly, if they allowed this sort of suffering to occur by treating lawless insurgents who go on to cause it, then the same principle is breached. Therefore, they should not be deployed when this would happen. (shrink)

The purpose of the study was to assess medical journals’ conflicts of interest in the publication of book reviews. We examined book reviews published in 1999, 2000, and 2001 in five leading medical journals: Annals of Internal Medicine, British Medical Journal, Journal of the American Medical Association, Lancet, and New England Journal of Medicine. The main outcome measure was journal publication of reviews of books that had been published by the journal’s own publisher, that had been (...) edited or authored by a lead editor of the journal, or that posed another conflict of interest. We also surveyed the editors-in-chief of the five journals about their policies on these conflicts of interests. During the study period, four of the five journals published 30 book reviews presenting a conflict of interest: nineteen by the BMJ, five by the Annals, four by JAMA, and two by the Lancet. These reviews represent 5.8%, 2.7%, 0.7%, and 0.7%, respectively, of all book reviews published by the journals. These four journals, respectively, published reviews of 11.9%, 25.0%, 0.9%, and 1.0% of all medical books published by the journals’ publishers. Only one of the 30 book reviews included a disclosure statement addressing the conflict of interest. None of the journals had a written policy pertaining to the conflicts of interest assessed in this study, although four reported having unwritten policies. We recommend that scientific journals and associations representing journal editors develop policies on conflicts of interest pertaining to book reviews. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Medical Tourism:Crossing Borders to Access Health CareHarriet Hutson Gray (bio) and Susan Cartier Poland (bio)Traveling abroad for one's health has a long history for the upper social classes who sought spas, mineral baths, innovative therapies, and the fair climate of the Mediterranean as destinations to improve their health. The newest trend in the first decade of the twenty-first century has the middle class traveling from developed countries to (...) those with emerging economies to avoid treatment delays, prohibitive costs for life-saving procedures, or simply high costs for elective surgery. Others leave to have access to assisted suicide in countries that have legalized it: Belgium, The Netherlands, and Switzerland. This new era of globalization in health care has arrived without the benefit of international standards, government oversight, or ethical and legal review.Howard Staab, a self-employed carpenter from North Carolina, flew to India for his medically necessary heart surgery, scheduled a side trip to the Taj Mahal, and returned home to work in North Carolina. He spent a total of less than $10,000, instead of the $200,000 required from the local hospital (I, Milstein and Smith 2006).At first blush, the outsourcing of medical care to India seems to be a particular solution for a particular problem. However, the particularity of Mr. Staab is not unique. His experience is emblematic of those patients in the United States with a medical need for major and elective procedures, but who also must bear the total cost of these procedures. These middle-class, under-insured Americans go abroad.In tandem with increasingly aggressive marketing campaigns, American hospitals and companies have begun to leverage their connections in Asia to grow the medical tourism business into a major economic force. What are the consequences of this?Several authors point to the effect on the host country's population, particularly the poor, to be pushed farther down the queue to receive adequate, affordable care. Resources are applied to the foreign trade instead of building the local [End Page 193] medical infrastructure. Another potential problem is the obligation of the home-country physician to provide follow-up care. What are the legal ramifications when the procedure was illegal to begin with? Are there opportunities for redress for medical errors?These factors may be converging into a "perfect storm" for health care in the U.S., in which the potential participation of the major insurance companies in promoting offshore care will be the tipping point in the precarious structure that represents the economic currents in health care. Third-party administrators and self-funded employers may be on the cutting edge in 2009 by providing incentives to employees to travel overseas for care.I. Economic ConsiderationsConnell, John. Medical Tourism: Sea, Sun, Sand and... Surgery. Tourism Management 27: 1093–1100, 2006.As evidence of the interest of traditional tour operators in this newer twist on the industry, the author explores medical tourism as an element of the growth of world tourism. In promoting medical tourism, he urges consideration of such issues as the privatization of health care, the foundational role of technology, and uneven access to health resources.Dunn, Philip. Medical Tourism Takes Flight. H and HN: Hospitals and Health Networks: 40–44, November 2007.Writing for U.S. health care executives, Dunn emphasizes that the reality of medical tourism competes with the local medical center for patients and their insurance dollars in a significant way. He examines the possibility that U.S. insurance plans soon may offer to pay for what is currently a cash only business and that the economic impact to the local medical center could be significant or even devastating.Frontiers of Health Services Management [Selected Articles] 24 (2), Winter 2007.In "Managing Healthcare Services in the Global Marketplace" (pp. 3–18), Bruce J. Fried and Dean M. Harris consider legal, ethical, and financial implications of the international workforce. In "Globalization of Health Care" (pp. 19–30), Lynn Schroth and Ruthy Khawahja point out that the transfer of comprehensive management expertise and intellectual property from U.S. medical centers to international sites is driving the success of collaboration between U.S. and foreign health care centers. In "Is... (shrink)

Two issues in Cowley’s book Medical Ethics, Ordinary Concepts and Ordinary Lives are discussed. The first is methodological and it concerns the relation between the personal and the impersonal perspectives. An apparent problem is represented by some uncertainties in the interpretation of their relation in Cowley’s proposal. In some cases presented by Cowley, although the agents do not give up the requirements of the personal perspective, their actions correspond to the requirements of the impersonal perspective. The question is how (...) did the agent make the decision? The other issue is that the personal perspective, as described in some cases, seems to be concerned only by reasons relevant to the subject herself. The question is whether such a perspective may be properly called moral, or it rather deserves to be qualified as prudential, egocentric or egoistic.The second issue regards organ donation, where Cowley contrasts the cultural discourse endorsed by people personally involved because of their links to the dead person, and the bioethicists’ discourse. Some empirical data seem to challenge this distinction. (shrink)

This article discusses chapters 15 and 16 of the ancient midrash Leviticus Rabba and its view of leprosy. The phenomenon of Biblical leprosy is here not investigated from a paleopathological point of view. The focus lies on its physiological, actiological, pathological and therapeutic aspects as represented in Leviticus Rabba. It is argued that the medical views of Leviticus Rabba show a certain resemblance to some of the view of the Hippocratic School, notably with respect to humoral theory, the belief (...) in the correspondence between the macrocosm and the individual microcosm, and the notion of paideia as a way of healing. Finally, it is shown that the ancient myth of the two floods is connected to the understanding of leprosy in Leviticus Rabba. (shrink)

Psychotherapists in mental health institutions as a professional group are part of the medical system, and from this perspective, as representing an occupation that serves the public health interests, as well as those of the individual seeking help. Despite the different existing therapeutic approaches and diverse forms of therapy deriving from these approaches critical theories, however, consider psychotherapy as a profession with a specific jurisdictional claim and own highly specific interests. In contrast to most of the recent discussion around (...) therapy culture, in this article, I argue that sociology and social theory could benefit from an understanding of psychotherapy as a profession with a separate logic and claim for jurisdiction for mental health. Moreover, I present some general trends showing that, regarding psychotherapy, we face a concurrence of a professionalisation, and simultaneously, an already ongoing deprofessionalisation. To develop my argument, I first discuss the perspectives of sociology of the psychotherapy professions. Second, I present the potential lack of professionalism in four dimensions. Third, I discuss possible tendencies of deprofessionalisation. Finally, I conclude by pointing out the importance of theorising the psychotherapy professions for medical sociology. (shrink)

The fact that monstrous births were not represented in independent learned publications of the eighteenth century, except for the case of hermaphrodites, does not mean that the interest in them had disappeared or that they were no more considered proper objects of inquiry. This paper focuses on the medical understanding of monstrosity at the Royal Society of London. I point to the use of monstrous births in strengthening the authority of medical practitioners and lecturers. I also show some (...) of their uses in providing new questions for the scenes of medical inquiry of the period and as crucial evidence in the understanding of regular physiological phenomena. I discuss some of the reasons why monstrous formations continued to defy an 'Enlightenment' approach to nature based on the search for order and regularity. (shrink)

Genetic testing has led to the establishment of the concept of the “previvor”: someone who is not yet sick, but who has a genetic predisposition to disease. The previvor experience demonstrates how the practice of medicine and medical decision making is evolving to render current law and policy increasingly inapplicable to modern medical practice. The introduction of previvorship to the medical landscape raises special issues for the physician-patient relationship and the legal doctrine of informed consent. It challenges (...) some of the most basic assumptions underlying the doctrine, is representative of the doctrine’s declining utility, and is illustrative of the need to transition to a shared decision-making model. Thus, we should begin to envision a legal doctrine that supports a robust shared decision-making approach to address individual preferences and values, the increasing complexity of risk/benefit assessment, and inherent (and sometimes irreducible) uncertainty. Such an approach should emphasize a new, more expansive, and inclusive model of illness. (shrink)

The Neurological Disease Ontology (ND) is being developed to provide a comprehensive framework for the representation of neurological diseases (Diehl et al., 2013). ND utilizes the model established by the Ontology for General Medical Science (OGMS) for the representation of entities in medicine and disease (Scheuermann et al., 2009). The goal of ND is to include information for each disease concerning its molecular, genetic, and environmental origins, the processes involved in its etiology and realization, as well as its clinical (...) presentation including signs and symptoms. (shrink)

The metamorphosis of human beings into wolves is well known in mythology, legend, and scripture, and has been extensively surveyed in history, theology, and literature. Werewolf cases have attracted the attention of both ancient and modern physicians, particularly during the development of modern psychiatry and behavioral neurology. Some writers have suggested that lycanthropes suffered from schizophrenia or had intentionally or involuntarily ingested hallucinogens. Hysteria and affective disorder, either mania or intense depression, could also be invoked as causes. Lycanthropy has often (...) been linked with, and sometimes treated by, henbane and nightshade, and its manifestations could be explained in terms of atropinic delirium. Discoloration of teeth and urine, bizarre behavior, nocturnal wandering, and episodic skin and facial changes have suggested a role for porphyria in the werewolf transformation. Through many historical periods and cultures, persons believed to be werewolves have reportedly exhibited alterations in consciousness, depersonalization and derealization, acute anxiety and agitation, preoccupation with demonic possession, and compulsive or perseverative behavior, sometimes of a violent, sexually deviant or impulsive nature. Such features of werewolf behavior might also be explained by ictal and interictal manifestations of complex partial seizures, or as symptoms of the episodic dyscontrol syndrome associated with frontal lobe or limbic system disease or injury. Lycanthropy was often considered a manifestation of demonic possession or a consequence or indication of participation in necromancy. As such, self-proclaimed or suspected werewolves were often persecuted along with other practitioners of the black arts. It is generally believed that such persecution represented the last efflorescence of medieval demonology, but it has also been suggested that clinical description of illnesses of diabolical origin was part of the evolution of Renaissance medicine from the Galenic past toward the scientifically-based future. (shrink)

In the present article I have surveyed several approaches to modeling the clinical diagnostic process. I have argued that at this point of the field's development, logics which simulate the reasoning patterns and knowledge base of expert clinicians represent research programs that are most likely to succeed. No logic of diagnosis has yet attained the status of being definitive; in spite of striking progress much more research and testing is required. On the basis of various existing logics, I have attempted (...) to articulate a number of desiderata which an ideal diagnostic logic should satisfy. In spite of these criticisms, I would maintain that programs such as MYCIN and INTERNIST have already matured to the point where they are useful both in consultations and in teaching diagnostic reasoning. (shrink)

All illness represents a state of diminished autonomy and therefore the doctor-patient relationship necessarily and justifiably involves a degree of medical paternalism argues the author, an American medical student. In a broad-ranging paper he discusses the concepts of autonomy and paternalism in the context of the doctor-patient relationship. Given the necessary diminution of autonomy which illness inflicts, a limited form of medical paternalism, aimed at restoring or maximising the patient's autonomy is entirely acceptable, and indeed fundamental to (...) the relationship he argues. However, the exercise of this paternalism should be flexible and related to the current 'level of autonomy' of the patient himself. An editorial in this issue comments briefly on this paper. (shrink)

Description Logics are nowadays widely accepted as formalisms which provide reasoning facilities which allow us to discover inconsistencies in ontologies in an automatic fashion. Where ontologies are developed in modular fashion, they allow changes in one module to propogated through the system of ontologies automatically in a way which helps to maintain consistency and stability. For this feature to be utilized effectively, however, requires that domain ontologies be represented in a normalized form.

Journals are failing in their obligation to ensure that research is fairly represented to their readers, and must act decisively to retract fraudulent publications. Recent case reports have exposed how marketing objectives usurped scientific testing and compromised the credibility of academic medicine. But scant attention has been given to the role that journals play in this process, especially when evidence of research fraud fails to elicit corrective measures. Our experience with The Journal of the American Academy of Child and Adolescent (...) Psychiatry (JAACAP) illustrates the nature of the problem. The now-infamous Study 329 of paroxetine in adolescent depression was negative for efficacy on all eight protocol-specified outcomes and positive for harm, but JAACAP published a report of this study that concluded that “paroxetine is generally well tolerated and effective for major depression in adolescents.” The journal’s editors not only failed to exercise critical judgment in accepting the paper, but when shown evidence that the paper misrepresented the science, refused either to convey this information to the medical community or to retract the article. (shrink)

Despite the recent advances in information and communication technology that have increased our ability to store and circulate information, the task of ensuring that the right sorts of information gets to the right sorts of people remains. We argue that the many efforts underway to develop efficient means for sharing information across healthcare systems and organizations would benefit from a careful analysis of human action in healthcare organizations. This in turn requires that the management of information and knowledge within healthcare (...) organizations be combined with models of resources and processes of patient care that are based on a general ontology of social interaction. The Health Level 7 (HL7) is one of several ANSI-accredited Standards Developing Organizations operating in the healthcare arena. HL7 has advanced a widely used messaging standard that enables healthcare applications to exchange clinical and administrative data in digital form. HL7 focuses on the interface requirements of the entire healthcare system and not exclusively on the requirements of one area of healthcare such as pharmacy, medical devices, imaging or insurance transactions. This has inspired the development of a powerful abstract model of patient care called the Reference Information Model (RIM). The present paper begins with an overview of the core classes of the HL7 (Version 3) RIM and a brief discussion of its “actcentered” view of healthcare. Central to this account is what is called the life cycle of events. A clinical action may progress from defined, through planned and ordered, to executed. These modalities of an action are represented as the mood of the act. We then outline the basis of an ontology of organizations, starting from the theory of speech Acts, and apply this ontology to the HL7 RIM. Special attention is given to the sorts of preconditions that must be satisfied for the successful performance of a speech act and to the sorts of entities to which speech acts give rise (e.g. obligations, claims, commitments, etc.). Finally we draw conclusions for the efficient communication and management of medical information and knowledge within and between healthcare organizations, paying special attention to the role that medical documents play in such organizations. (shrink)

Medical-legal partnerships (MLPs) — collaborative endeavors between health care clinicians and lawyers to more effectively address issues impacting health care — have proliferated over the past decade. The goal of this interdisciplinary approach is to improve the health outcomes and quality of life of patients and families, recognizing the many non-medical influences on health care and thus the value of an interdisciplinary team to enhance health. This article examines the unique, interrelated ethical issues that confront the clinical and (...) legal partners involved in MLPs. We contend that the ethical precepts of the clinical and legal professions should be seen as opportunities, not barriers, to further the interdisciplinary nature of MLPs. The commonalities in ethical approaches represent a potential bridge between legal and health care advocacy for patient/client well-being. Bioethics has a role to play in building and analyzing this bridge: bioethics may serve as a discourse and method to enhance collaboration by highlighting common ethical foundations and refocusing legal and clinical partners on their similar goals of service for patients/clients. This article explores this bridging role of bioethics, through a series of case studies. It concludes with recommendations to strengthen the collaborations. (shrink)

Education, medicine and psychotherapeutics offer exemplary sites through which liberty and its dreams are realized. This article explores the social history of medical freedom and liberty in North America during the late nineteenth and early twentieth centuries. The National League for Medical Freedom (NLMF) and the American Medical Liberty League (AMLL) offered fierce resistance to allopathic power. Allopatic liberties and rights to medical practice in asylums, clinics, courts, hospitals, prisons and schools were never certain. The politics (...) of these liberties and rights represents a fascinating story that neither intellectual nor social historians have fully appreciated. (shrink)

The paper argues in favor of bioethics as an alternative to traditional medical ethics. Relations between the patient and the doctor placed in the bioethical context are considered as a part of more general, global issues: relations between clients, customers, various (including non-medical) services and the professional medical community and society in general, world-renowned scientists and the international community. Medical ethics is seen in the wider expanse of diverse economic, political and cultural relations not only in (...) terms of responsibilities but also natural rights which all people have without exception and with regard to professional identity. In contrast to traditional medical ethics, bioethics not only encourages one to reconsider the content of human morality, which is built on interpersonal relations, but also shows that disease and health are not merely medical phenomena. In this situation, paramount importance is assigned to interests of the client and society rather than medical corporations. Such a transformation of medical theory and practice requires public discussion of professional ethics issues and external regulation control. There is a need to develop ethical criteria for medical activity not only at the national but also international, or even global, levels, as well as criteria for long-term effects of highly technological professional medical practice. Bioethics expands the boundaries of professional medical ethics and ethical reflection of its normative foundations as it carries out both internal (code of ethics) and external (ethics committees and commission) “regulation” of professional practice. The purpose of bioethics is the preservation and development of life represented not only by man but also other creatures, which has never been on the agenda of medical ethics. (shrink)

While every health care system stakeholder would seem to be concerned with obtaining the greatest value from a given technology, there is often a disconnect in the perception of value between a technology’s promoters and those responsible for the ultimate decision as to whether or not to pay for it. Adopting an empirical ethics approach, this paper examines how five Canadian medical device manufacturers, via their websites, frame the corporate “value proposition” of their innovation and seek to respond to (...) what they consider the key expectations of their customers. Our analysis shows that the manufacturers’ framing strategies combine claims that relate to valuable socio-technical goals and features such as prevention, efficiency, sense of security, real-time feedback, ease of use and flexibility, all elements that likely resonate with a large spectrum of health care system stakeholders. The websites do not describe, however, how the innovations may impact health care delivery and tend to obfuscate the decisional trade-offs these innovations represent from a health care system perspective. Such framing strategies, we argue, tend to bolster physicians’ and patients’ expectations and provide a large set of stakeholders with powerful rhetorical tools that may influence the health policy arena. Because these strategies are difficult to counter given the paucity of evidence and its limited use in policymaking, establishing sound collective health care priorities will require solid critiques of how certain kinds of medical devices may provide a better (i.e., more valuable) response to health care needs when compared to others. (shrink)

We argue that a turn toward virtue ethics as a way of understanding medical professionalism represents both a valuable corrective and a missed opportunity. We look at three ways in which a closer appeal to virtue ethics could help address current problems or issues in professionalism education—first, balancing professionalism training with demands for professional virtues as a prerequisite; second, preventing demands for the demonstrable achievement of competencies from working against ideal professionalism education as lifelong learning; and third, avoiding temptations (...) to dismiss moral distress as a mere “hidden curriculum” problem. As a further demonstration of how best to approach a lifelong practice of medical virtue, we will examine altruism as a mean between the extremes of self-sacrifice and selfishness. (shrink)

We provide here a general mathematical framework to model attitudes towards ambiguity which uses the formalism of quantum theory as a “purely mathematical formalism, detached from any physical interpretation”. We show that the quantum-theoretic framework enables modelling of the Ellsberg paradox, but it also successfully applies to more concrete human decision-making tests involving financial, managerial and medical decisions. In particular, we elaborate a mathematical representation of various empirical studies which reveal that attitudes of managers towards uncertainty shift from ambiguity (...) seeking to ambiguity aversion, and viceversa, thus exhibiting hope effects and fear effects. The present framework provides a promising direction towards the development of a unified theory of decisions in the presence of uncertainty. (shrink)

Over the last century Christian ethics has moved from an attempt to Christianize the social order to a quandary over whether being Christian unduly biases how medical ethics is done. This movement can be viewed as the internal development of protestant liberalism to its logical conclusion, and Paul Ramsey can be taken as one of the last great representatives of that tradition. By reducing the Christian message to the ‘ethical upshot’ of neighbour love, Ramsey did not have the (...) resources to show how Christian practice might make a difference for understanding or forming the practice of medicine. Instead, medicine became the practice that exemplified the moral commitments of Christian civilization, and the goal of the ethicist was to identify the values that were constitutive of medicine. Ramsey thus prepared the way for the Christian ethicist to become a medical ethicist with a difference, and the difference simply involved vague theological presumptions that do no serious intellectual work other than explaining, perhaps, the motivations of the ethicist. (shrink)

Many current abortion regulations represent an over-medicalization of abortion or a corruption of abortion's true medical nature, with disproportionate consequences to women with lower incomes and lesser means. This article explores the effects of unnecessary and harmful abortion restrictions on women living in poverty. A brief summary of the major abortion rights cases explains how the Constitution, as currently interpreted, vests the government and sometimes the medical profession with the power to protect women's health, rather than granting this (...) power to women themselves. The article then argues for a new approach for protecting women's health and respecting their dignity by reframing reproductive rights as health rights that women themselves can assert. (shrink)

Despite legislation and public education, racism and sexism are alive and well. Though pre‐conceptive gender selection may enhance procreative liberty, this technology presents two disturbing questions. First, does sex selection represent underlying parental sexism? Second, by performing gender selection, do medical professionals perpetuate sexism? It will be maintained that pre‐conceptive sex selection is sexist as it reflects parental anticipation of stereotypical gender based behavior. Perhaps even more incriminating, sex selection forces parents to prefer one sex over another, to place (...) a value on gender. This emphasis on sex conflicts with societal goals which urge, and often legally require, individuals to ignore gender. We will assert that pre‐conceptive gender selection exemplifies sexism in its purest most blatant form as prior to conception, before parents can possibly know anything about their child, gender dominates the calculus of a child’s worth. We will also emphasize that physicians, by facilitating sex selection, legitimize the motivations of their patients and provide de facto support of sexism. In a similar vein, arguments against pre‐conceptive race selection will be made. (shrink)

Mildred Cho and Nicole Martinez-Martin (2023) distinguish between two of the ways in which humans can be represented in medical contexts. One is technical: a digital model of aspects of a person’s...