Now I know why so many stories have been written with the theme: “everything changed in one moment.” More than 1,000 days have come and gone, and I still remember one Sunday morning and still follow and feel the effects of one decision.

Over the last 50 years, the term professionalism has undergone a widespread expansion in its use and a semantic shift in its meaning. As a result, it is at risk of losing its descriptive and analytical value and becoming instead simply an empty evaluative label, a fate described by C. S. Lewis as ‘verbicide’. This article attempts to rescue professionalism from this fate by down-sizing its extension and reassigning some of its work to two other ethical domains, introduced as the (...) neologisms organizationalism and sur-moralism. Professionalism is defined as a morality based in system of obligations that are assumed by physicians over the course of their professional training and which primarily refer to two groups: patients and colleagues, including trainees. Organizationalism is also a morality, but the obligations are owed to the employing organization and on different grounds. A third ethical domain, here called sur-moralism, comprises actions that are not based in obligations. They are discretionary and potentially meritorious; they cannot be required by the profession or organization. This article presents a conceptual model of the three ethical domains and the shifting borders between them. One practical benefit of this typology is that physicians can more accurately understand the nature and sources of obligations that they are asked to accept, and when necessary prioritize them. Another is that physicians will be able to describe the potential tension between the three domains and understand how and why the borders between them can move. Both should help physicians to be more ethically oriented to their work settings. (shrink)

Background:The global COVID-19 pandemic has imposed challenges on healthcare systems and professionals worldwide and introduced a ´maelstrom´ of ethical dilemmas. How ethically demanding situations are handled affects employees’ moral stress and job satisfaction.Aim:Describe priority-setting dilemmas, moral distress and support experienced by nurses and physicians across medical specialties in the early phase of the COVID-19 pandemic in Western Norway.Research design:A cross-sectional hospital-based survey was conducted from 23 April to 11 May 2020.Ethical considerations:Ethical approval granted by the Regional Research Ethics Committee in (...) Western Norway (131421).Findings:Among the 1606 respondents, 67% had experienced priority-setting dilemmas the previous two weeks. Healthcare workers who were directly involved in COVID-19 care, were redeployed or worked in psychiatry/addiction medicine experienced it more often. Although 59% of the respondents had seen adverse consequences due to resource scarcity, severe consequences were rare. Moral distress levels were generally low (2.9 on a 0–10 scale), but higher in selected groups (redeployed, managers and working in psychiatry/addiction medicine). Backing from existing collegial and managerial structures and routines, such as discussions with colleagues and receiving updates and information from managers that listened and acted upon feedback, were found more helpful than external support mechanisms. Priority-setting guidelines were also helpful.Discussion:By including all medical specialties, nurses and physicians, and various institutions, the study provides information on how the COVID-19 mitigation also influenced those not directly involved in the COVID-19 treatment of patients. In the next stages of the pandemic response, support for healthcare professionals directly involved in outbreak-affected patients, those redeployed or those most impacted by mitigation strategies must be a priority.Conclusion:Empirical research of healthcare workers experiences under a pandemic are important to identify groups at risks and useful support mechanisms. (shrink)

In Pakistan, as in many non‐Western cultures, decisions about a patient's health care are often made by the family or the doctor. For doctors educated in the West, the Pakistani approach requires striking a balance between preserving indigenous values and carving out room for patients to participate in their medical decisions.

BackgroundDefensive practice occurs when physicians provide services, such as tests, treatments and referrals, mainly to reduce their perceived legal or reputational risks, rather than to advance patient care. This behaviour is counter to physicians’ ethical responsibilities, yet is widely reported in surveys of doctors in various countries. There is a lack of qualitative research on the drivers of defensive practice, which is needed to inform strategies to prevent this ethically problematic behaviour.MethodsA qualitative interview study investigated the views and experiences of (...) physicians in Australia on defensive practice and its contribution to low value care. Interviewees were recruited based on interest in medico-legal issues or experience in a health service involved in ‘Choosing Wisely’ initiatives. Semi-structured interviews averaged 60 min in length. Data were coded using the Theoretical Domains Framework, which encapsulates theories of behaviour and behaviour change.ResultsAll participants (n = 17) perceived defensive practice as a problem and a contributor to low value care. Behavioural drivers of defensive practice spanned seven domains in the TDF: knowledge, focused on inadequate knowledge of the law and the risks of low value care; skills, emphasising patient communication and clinical decision-making skills; professional role and identity, particularly clinicians’ perception of patient expectations and concern for their professional reputation; beliefs about consequences, especially perceptions of the beneficial and harmful consequences of defensive practice; environmental context and resources, including processes for handling patient complaints; social influences, focused on group norms that encourage or discourage defensive behaviour; and emotions, especially fear of missing a diagnosis. Overall, defensive practice is motivated by physicians’ desire to avoid criticism or scrutiny from a range of sources, and censure from their professional peers can be a more potent driver than perceived legal consequences.ConclusionsThe findings call for strengthening knowledge and skills, for example, to improve clinicians’ understanding of the law and their awareness of the risks of low value care and using effective communication strategies with patients. Importantly, supportive cultures of practice and organisational environments are needed to create conditions in which clinicians feel confident in avoiding defensive practice and other forms of low value care. (shrink)

While twentieth-century medical ethics has focused on the duty of physicians to benefit their patients, the next century will see that duty challenged in three ways. First, we will increasingly recognize that it is unrealistic to expect physicians to be able to determine what will benefit their patients. Either they limit their attention to medical well-being when total well-being is the proper end of the patient or they strive for total well-being, which takes them beyond their expertise. Even within the (...) medical sphere, they have no basis for choosing among the proper medical goals for medicine. Also, there are many plausible strategies for relating predicted benefits to harms, and physicians cannot be expert in picking among these strategies. Second, increasingly plausible ethical systems recognize that in some cases, patient benefit must be sacrificed to protect patient rights including the right to the truth, to have promises kept, to have autonomy respected, and to not be killed. Third, ethics of the next century will increasingly recognize that some patient benefits must be sacrificed to fulfill duties to others - either the duty to serve the interests of others or other duties such as keeping promises, telling the truth, and, particularly, promoting justice. Physicians in the twenty-first century will be seen as having a new, more limited duty to assist the patient in pursuing the patient's understanding of the patient's interest within the constraints of deontological ethical principles and externally imposed duties to promote justice. The result will be a duty to be loyal to the consumer of health care with the recognition that often this will mean that the physician is not permitted to pursue the physician's understanding of the patient's well-being. (shrink)

Using medical advances to enhance human athletic, aesthetic, and cognitive performance, rather than to treat disease, has been controversial. Little is known about physicians? experiences, views, and attitudes in this regard. We surveyed a national sample of physicians to determine how often they prescribe enhancements, their views on using medicine for enhancement, and whether they would be willing to prescribe a series of potential interventions that might be considered enhancements. We find that many physicians occasionally prescribe enhancements, but doctors hold (...) nuanced and ambiguous views of these issues. Most express concerns about the potential effects of enhancements on social equity, yet many also believe specific enhancements that are safe and effective should be available but not covered by insurance. These apparently contradictory views might reflect inherent tensions between the values of equity and liberty, which could make crafting coherent social policies on medical enhancements challenging. [Supplementary materials are available for this article. Go to the publisher's online edition of American Journal of Bioethics for the following free supplemental resource(s): An additional table (Table 5) referred to on p. 5]. (shrink)

Nurses and physicians may experience ethical conflict when there is a difference between their own values, their professional values or the values of their organization. The distribution of limited health care resources can be a major source of ethical conflict. Relatively few studies have examined nurses' and physicians' ethical conflict with organizations. This study examined the research question ‘What are the organizational ethical conflicts that hospital nurses and physicians experience in their practice?’ We interviewed 34 registered nurses, 10 nurse managers, (...) and 31 physicians as part of a larger study, and asked them to describe their ethical conflicts with organizations. Through content analysis, we identified themes of nurses' and physicians' ethical conflict with organizations and compared the themes for nurses with those for physicians. (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)

*The views in this article are the author's alone and should not be construed as policy statements of the American Medical Association.

Psyche and Soma is a multi-disciplinary exploration of the history of understanding of the human mind or soul and its relationship to the body, through the course of more than two thousand years. Thirteen specially commissioned chapters, each written by a recognized expert, discuss such figures as the doctors Hippocrates and Galen, the theologians St Paul, Augustine, and Aquinas, and philosophers from Plato to Leibniz.

A survey of the recent literature suggests that physicians should engage religious patients on religious grounds when the patient cites religious considerations for a medical decision. We offer two arguments that physicians ought to avoid engaging patients in this manner. The first is the Public Reason Argument. We explain why physicians are relevantly akin to public officials. This suggests that it is not the physician’s proper role to engage in religious deliberation. This is because the public character of a physician’s (...) role binds him/her to public reason, which precludes the use of religious considerations. The second argument is the Fiduciary Argument. We show that the patient-physician relationship is a fiduciary relationship, which suggests that the patient has the clinical expectation that physicians limit themselves to medical considerations. Since engaging in religious deliberations lies outside this set of considerations, such engagement undermines trust and therefore damages the patient-physician relationship. (shrink)

Developments in Machine Learning (ML) have attracted attention in a wide range of healthcare fields to improve medical practice and the benefit of patients. Particularly, this should be achieved by providing more or less automated decision recommendations to the treating physician. However, some hopes placed in ML for healthcare seem to be disappointed, at least in part, by a lack of transparency or traceability. Skepticism exists primarily in the fact that the physician, as the person responsible for diagnosis, therapy, and (...) care, has no or insufficient insight into how such recommendations are reached. The following paper aims to make understandable the specificity of the deliberative model of a physician-patient relationship that has been achieved over decades. By outlining the (social-)epistemic and inherently normative relationship between physicians and patients, I want to show how this relationship might be altered by non-traceable ML recommendations. With respect to some healthcare decisions, such changes in deliberative practice may create normatively far-reaching challenges. Therefore, in the future, a differentiation of decision-making situations in healthcare with respect to the necessary depth of insight into the process of outcome generation seems essential. (shrink)

Ethical dilemmas are part of medicine, but the type of challenges, the frequency of their occurrence and the nuances in the difficulties have not been systematically studied in low-income settings. The objective of this paper was to map out the ethical dilemmas from the perspective of Ethiopian physicians working in public hospitals. A national survey of physicians from 49 public hospitals using stratified, multi-stage sampling was conducted in six of the 11 regions in Ethiopia. Descriptive statistics were used and the (...) responses to the open-ended question “If you have experienced any ethical dilemma, can you please describe a dilemma you have encountered in your own words?” were analyzed using a template analysis process. A total of 587 physicians responded, and 565 met the inclusion criteria. Twelve of 24 specified ethically challenging situations were reported to be experienced often or sometimes by more than 50% of the physicians. The most frequently reported challenge concerned resource distribution: 93% agreed that they often or sometimes had to make difficult choices due to resource limitation, and 83% often or sometimes encountered difficulties because patients were unable to pay for the preferred course of treatment. Other frequently reported difficulties were doubts about doing good or harming the patient, relating to conflicting views, concern for family welfare, disclosure issues and caring for patients not able to consent. Few reported dilemmas related to end-of-life issues. The 200 responses to the open-ended question mirrored the quantitative results. Ethiopian physicians report ethical challenges related more to bedside rationing and fairness concerns than futility discussions and conflicts about autonomy as described in studies from high-income countries. In addition to the high report of experienced challenges, gravity of the dilemmas that are present in their narratives are striking. Recognition of the everyday experiences of physicians in low-income settings should prompt the development of ethics teaching and support mechanisms, discussion of ethical guidelines as well as increase our focus on how to improve the grave resource scarcity they describe. (shrink)

Three female physicians were interviewed as part of a comprehensive investigation into the narratives of female and male physicians and nurses, concerning their experience of being in ethically difficult care situations in the care of elderly people. The interviewees expressed great concern for the low status of care for elderly people, and the need to fight for the specialty and for the care and rights of their patients. All the interviewees’ narratives concerned problems relating to perspectives of both action ethics (...) and relational ethics. The main focus was on problems concerning the latter perspective, expressed as profound concern and respect for the individual patient. Secondary emphasis was placed on relationships with relatives and other professionals. The most common themes in an action ethics perspective were too little treatment and the lack of health services for older patients, together with overtreatment and death with dignity. These results were discussed in the light of Løgstrup’s ethics, which emphasize that human life means expressing oneself, in the expectation of being met by others. Both Ricoeur’s concept of an ethics of memory and Aristotle’s virtue ethics are presented in the discussion of too little and too much treatment. (shrink)

Pediatric oncology has a strong research culture. Most pediatric oncologists are investigators, involved in clinical care as well as research. As a result, a remarkable proportion of children with cancer enrolls in a trial during treatment. This paper discusses the ethical consequences of the unprecedented integration of research and care in pediatric oncology from the perspective of parents and physicians. An empirical ethical approach, combining (1) a narrative review of (primarily) qualitative studies on parents' and physicians' experiences of the pediatric (...) oncology research practice, and (2) comparison of these experiences with existing theoretical ethical concepts about (pediatric) research. The use of empirical evidence enriches these concepts by taking into account the peculiarities that ethical challenges pose in practice. Analysis of the 22 studies reviewed revealed that the integration of research and care has consequences for the informed consent process, the promotion of the child's best interests, and the role of the physician (doctor vs. scientist). True consent to research is difficult to achieve due to the complexity of research protocols, emotional stress and parents' dependency on their child's physician. Parents' role is to promote their child's best interests, also when they are asked to consider enrolling their child in a trial. Parents are almost never in equipoise on trial participation, which leaves them with the agonizing situation of wanting to do what is best for their child, while being fearful of making the wrong decision. Furthermore, a therapeutic misconception endangers correct assessment of participation, making parents inaccurately attribute therapeutic intent to research procedures. Physicians prefer the perspective of a therapist over a researcher. Consequently they may truly believe that in the research setting they promote the child's best interests, which maintains the existence of a therapeutic misconception between them and parents. Due to the integration of research and care, their different ethical perspectives become intertwined in the daily practice of pediatric oncology. Increasing awareness of what this means for the communication between parents and physicians is essential. Future research should focus on efforts that overcome the problems that the synchronicity of research and care evokes. (shrink)

Background Since the enactment of the euthanasia law in the Netherlands, there has been a lively public debate on assisted dying that may influence the way patients talk about euthanasia and physician-assisted suicide with their physicians and the way physicians experience the practice of EAS. Aim To show what developments physicians see in practice and how they perceive the influence of the public debate on the practice of EAS. Methods We conducted a secondary analysis of in-depth interviews with 28 Dutch (...) physicians who had experience with a complex case of EAS. Respondents were recruited both by the network of physicians working for SCEN as well as via a national questionnaire, wherein participating physicians could indicate their willingness to be interviewed. Results Three themes came up in analysing the interviews. First, the interviewed physicians experienced a change in what patients would expect from them: from a role as an involved caregiver to being the mere performer of EAS. Second, interviewees said that requests for EAS based on non-medical reasons came up more frequently and wondered if EAS was the right solution for these requests. Last, respondents had the impression that the standards of EAS are shifting and that the boundaries of the EAS regulation were stretched. Conclusions The perceived developments could make physicians less willing to consider a request for EAS. Our results also raise questions about the role of physicians and of EAS in society. (shrink)

OBJECTIVES: Life-sustaining treatment at the end of life gives rise to many ethical problems in Japan. Recent surveys of Japanese physicians suggested that they tend to treat terminally ill patients aggressively. We studied why Japanese physicians were reluctant to withhold or withdraw life-support from terminally ill patients and what affected their decisions. DESIGN AND PARTICIPANTS: A qualitative study design was employed, using a focus group interview with seven physicians, to gain an in-depth understanding of attitudes and rationales in Japan regarding (...) medical care at the end of life. RESULTS: Analysis revealed that physicians and patients' family members usually make decisions about life-sustaining treatment, while the patients' wishes are unavailable or not taken into account. Both physicians and family members tend to consider withholding or withdrawing life-sustaining treatment as abandonment or even killing. The strongest reason to start cardiopulmonary resuscitation- and to continue it until patients' family members arrive-seems to be the family members' desire to be at the bedside at the time of death. All physicians participating in our study regarded advance directives that provide information as to patients' wishes about life-sustaining treatment desirable. All expressed concern, however, that it would be difficult to forego or discontinue life-support based on a patient's advance directive, particularly when the patient's family opposed the directive. CONCLUSION: Our group interview suggested several possible barriers to death with dignity and the appropriate use of advance directives in Japan. Further qualitative and quantitative research in this regard is needed. (shrink)

We report the results of an investigation of nurses’ and physicians’ sensitivity to ethical dimensions of clinical practice. The sample consisted of 113 physicians working in general medical settings, 665 psychiatrists, 150 nurses working in general medical settings, and 145 nurses working in psychiatry. The instrument used was the Moral Sensitivity Questionnaire (MSQ), a self-reporting Likert-type questionnaire consisting of 30 assumptions related to moral sensitivity in health care practice. Each of these assumptions was categorized into a theoretical dimension of moral (...) sensitivity: relational orientation, structuring moral meaning, expressing benevolence, modifying autonomy, experiencing moral conflict, and following the rules. Significant differences in responses were found between health care professionals from general medical settings and those working in psychiatry. The former agreed to a greater extent with the assumptions in the categories ‘meaning’ and ‘autonomy’ and to a lesser degree with the categories ‘benevolence’ and ‘conflict’. Moreover, those from the psychiatric sector agreed to a greater extent to the use of coercion if necessary. Significant differences were also found for some of the MSQ categories, between physicians and nurses, and between males and females. (shrink)

BackgroundBreaking bad news to mothers whose children has disability is an important role of physicians. There has been considerable speculation about the inevitability of parental dissatisfaction with how they are informed of their child’s disability. Egyptian mothers’ preferences for how to be told the bad news about their child’s disability has not been investigated adequately. The objective of this study was to elicit Egyptian mothers’ preferences for how to be told the bad news about their child’s disability.MethodsMothers of 100 infants (...) recently diagnosed with Down syndrome were interviewed regarding their preferences for how to be told bad news. Mothers were recruited through outpatient clinics of the Pediatric Genetics Department at Fayoum University Hospital (located 90 km southwest of Cairo, Egypt) from January to June 2011.Results and discussionQuestionnaire analyses revealed nine themes of parental preferences for how to be told information difficult to hear. Mothers affirmed previously reported recommendations for conveying bad medical news to parents, including being told early, being told of others with a similar condition, and being informed of the prognosis.ConclusionsMothers affirmed communication themes previously discussed in the literature, such as being told early, and being informed of the prognosis. Although more research is needed in this important area, we hope that our findings will stimulate future search and help health care providers in different societies establish guidelines for effectively communicating bad news. (shrink)

Background: Advances in biomedical sciences, technologies and care practices have resulted in an increase in ethical problems and a resulting growth of difficulties encountered by health workers in their professional activity. Objective: The main objective of this study was to analyse knowledge in the ethical field and experience with and the propensity for using ethics consultations by nurses and physicians. Methods: Between March and June 2014, a cross-sectional observational study was conducted on a sample of 351 nurses and 128 physicians (...) in four central Italian hospitals. For data collection, a semi-structured questionnaire was used, consisting of 21 items divided into four sections exploring demographic and occupational characteristics, knowledge in the ethics field, experience with ethical issues and the propensity to use ethics consultation. Ethical considerations: Research ethics approval was obtained from the Italian Nurses Professional Board. Results: The results show that both nurses and physicians are faced with ethically sensitive situations. Nurses were found to have better judgement concerning their own knowledge than physicians, but more physicians were found to have a deeper level of specific training in ethics issues. The propensity to ask for ethics consultations to address ethical issues was found to be significantly associated with the degree to which ethical issues have deepened. Conclusion: The presence of a consulting service that can lead to shared choices may represent, together with basic and continuing education, a valid support for professional growth in the ethical field for both physicians and nurses. (shrink)

Clinical psychologists' and nonpsychiatric physicians' attitudes and behaviors in sexual and confidentiality boundary violations were examined. The 171 participants' responses were analyzed by profession, sex, and status (student, resident, professional) on semantic differential, boundary violation vignettes, and a version of Pope, Tabachnick, and Keith-Spiegel's (1987) ethical scale. Psychologists rated sexual boundary violation as more unethical than did physicians (p<.001). Rationale (p<.01) and timing (p<.001) influenced ratings. Psychologists reported fewer sexualized behaviors than physicians (p<05). Professional experience (p<.01) and sex (p<.05) were (...) associated with confidence-violating behavior. Overall, 78% of the sample reported attitudes or behaviors associated with boundary violations. The behavior violations were correlated (r=.49). Actual violators rated vignette violators more leniently than did nonviolators (p<.01). (shrink)

Patients in Quebec can legally obtain medical assistance in dying (MAID) if they are able to give informed consent, have a serious and incurable illness, are at the end of their lives and are in a situation of unbearable suffering. Since the Supreme Court of Canada’s 2015 Carter decision, access to MAID, under certain conditions, has become a constitutional right. Quebec physicians are now likely to receive requests for MAID from their patients. The Quebec and Canadian laws recognize a physician’s (...) right to conscientious objection, but this right is contested both in the medical ethics literature and in the public sphere. This paper presents the results of a qualitative study conducted with twenty Quebec physicians who did not integrate MAID into their medical practice, either because they were opposed to or deeply ambivalent about MAID. The interviews aimed to explore the reasons – religious and secular – for opposition to or ambivalence towards MAID. The secular reasons given by participants were grouped into four main categories: 1) the ends of medicine and professional identity, 2) the philosophy of palliative medicine and resource allocation in palliative care, 3) benevolent paternalism, the “good death”, and the interests of future selves, 4) the risk of a slippery slope and the protection of vulnerable people. (shrink)

Background In current Western medical ethics, patient-centered medicine is considered the norm. However, the cultural background of collectivism in East Asia often leads to family-centered decision-making. In Japan, prior studies have reported that family-centered decision-making is more likely to be preferred in situations of disease notification and end-of-life decision-making. Nonetheless, there has been a recent shift from collectivism to individualism due to changes in the social structure. Various personal factors have also been reported to influence moral decision-making. Therefore, this study (...) examined whether the current trend in attitudes of healthcare decision-making in Japan is family-centered or patient-centered among the general public and physicians. In addition, the personal factors that influence this tendency were examined.Methods Three vignettes on disease notification and two vignettes on decision-making during end-of-life care were created, and 457 members of the public and 284 physicians were asked about their attitudes (behavioral intentions) regarding these vignettes.Results Approximately, 95% of physicians were patient-centered in explaining the patient’s severe medical condition. However, approximately 80% of physicians emphasized the wishes of the family over patient wishes when making life-sustaining decisions. Nearly half the general public emphasized the patient’s wishes in the explanation of a severe medical condition and in life-sustaining decisions. In both the public and physician groups, personal factors, particularly the presence or absence of a disease under treatment and prior caregiving experience, influenced ethical attitudes toward medical treatment decisions.Conclusions In relatively low-conflict situations, such as the announcement of a patient’s medical condition, physicians tended to be patient-centered, while they tended to be family-centered in situations of strong conflict in withholding life-sustaining treatment. The fact that personal factors influenced the family-centered response in situations of strong conflict highlights the importance of not only acquiring knowledge of medical ethics but also learning to fairly apply this knowledge in practice. (shrink)

Clinical Ethics Consultations are an important tool for physicians in solving difficult cases. They are extremely common in North America and to a lesser extent also present in Europe. However, there is little data on this practice in Poland. We present results of a survey of 521 physicians practising in Poland concerning their opinion on CECs and related practices. We analysed the data looking at such issues as CECs’ perceived availability, use of CECs, and perceived usefulness of such support. Physicians (...) in our study generally encounter hard ethics cases, even—surprisingly—those who do not work in hospitals. Most physicians have no CEC access, and those that do still do not employ CECs. However, physicians perceive this form of support as useful—even more so among actual users of CECs. We compared these findings with similar studies from other European countries and the North America. We point out peculiarities of our results as compared to those in other countries, with some possible explanations. We hope the results may encourage regulatory debate on the need to formally introduce CECs into the Polish healthcare system. (shrink)

Within any organization (e.g. a hospital or clinic) the perception of the way things operate may vary dramatically as a function of one’s location in the organizational hierarchy as well as one’s professional discipline. Interorganizational variability depends on organizational coherence, safety, and stability. In this four-nation (Canada, Ireland, Australia, and Korea) qualitative study of 42 nurses, we explored their perception of how ethical decisions are made, the nurses’ hospital role, and the extent to which their voices were heard. These nurses (...) suggested that their voices were silenced (often voluntarily) or were not expressed in terms of ethical decision making. Finally, they perceived that their approach to ethical decision making differed from physicians. (shrink)

This paper proposes that billing gamesmanship occurs when physicians free-ride on the billing practices of other physicians. Gamesmanship is non-universalizable and does not exercise a competitive advantage; consequently, it distorts prices and allocates resources inefficiently. This explains why gamesmanship is wrong. This explanation differs from the recent proposal of Heath (2020. Ethical issues in physician billing under fee-for-service plans. J. Med. Philos. 45(1):86–104) that gamesmanship is wrong because of specific features of health care and of health insurance. These features are (...) aggravating factors but do not explain gamesmanship’s primary wrong-making feature, which is to cause diffuse harm not traceable to any particular patient or insurer. This conclusion has important consequences for how medical schools and professional organizations encourage integrity in billing. To avoid free-riding, physicians should ask themselves, “could all physicians bill this way?” and if not, “does the patient benefit from the distinctive service I am providing under this code?” If both answers are “no,” physicians should refrain from the billing practice in question. (shrink)

There have been few empirical studies into what non-medical factors influence physicians and nurses when deciding about admission and discharge of ICU patients. Information about the attitudes of healthcare professionals about this process can be used to improve decision-making about resource allocation in intensive care. To provide insight into ethical problems that influence the ICU admission and discharge process, we aimed to identify and explore ethical dilemmas healthcare professionals are faced with.

DNR decisions are frequently made in oncology and hematology care and physicians and nurses may face related ethical dilemmas. Ethics is considered a basic competence in health care and can be understood as a capacity to handle a task that involves an ethical dilemma in an adequate, ethically responsible manner. One model of ethical competence for healthcare staff includes three main aspects: being, doing and knowing, suggesting that ethical competence requires abilities of character, action and knowledge. Ethical competence can be (...) developed through experience, communication and education, and a supportive environment is necessary for maintaining a high ethical competence. The aim of the present study was to investigate how nurses and physicians in oncology and hematology care understand the concept of ethical competence in order to make, or be involved in, DNR decisions and how such skills can be learned and developed. A further aim was to investigate the role of guidelines in relation to the development of ethical competence in DNR decisions. Individual interviews were conducted with fifteen nurses and sixteen physicians. The interviews were analyzed using thematic content analysis. Physicians and nurses in the study reflected on their ethical competence in relation to DNR decisions, on what it should comprise and how it could be developed. The ethical competence described by the respondents related to the concepts being, doing and knowing. In order to make ethically sound DNR decisions in oncology and hematology care, physicians and nurses need to develop appropriate virtues, improve their knowledge of ethical theories and relevant clinical guidelines. Ethical competence also includes the ability to act upon ethical judgements. Continued ethical education and discussions for further development of a common ethical language and a good ethical working climate can improve ethical competence and help nurses and physicians cooperate better with regard to patients in relation to DNR decisions, in their efforts to act in the best interest of the patient. (shrink)

In June 2001, the American Medical Association (AMA) issued a revised and expanded version of the Principles of Medical Ethics (last published in 1980). In light of the new and more comprehensive document, the present essay is geared to consideration of a longstanding tension between physician's autonomy rights and societal obligations in the AMA Code. In particular, it will be argued that a duty to treat overrides AMA autonomy rights in social emergencies, even in cases that involve personal risk to (...) physicians (e.g., bioterrorist attack, HIV infection, SARS). The argument will be made by way of the logic and language of the AMA Code through its history, commentaries, and precedents. It also will be shown that there are substantial reasons to believe that the logic of the Code is sound in morally relevant ways. The essay will conclude with some philosophical proposals suggesting a framework for the duty to render aid and the extension of those duties to physicians facing personal risks. (shrink)

In this qualitative study, we aimed to identify and compare the ethical problems perceived by physicians and nurses in intensive care units at Baskent University hospitals in Turkey. A total of 21 physicians and 22 nurses were asked to describe ethical problems that they frequently encounter in their practice. The data were analyzed using an interactive model. The core problem for both physicians and nurses was end-of-life decisions (first level). In this category, physicians were most frequently concerned with euthanasia while (...) nurses were more concerned with do-not-resuscitate orders (second level). At the third level, we saw that almost all of the participants’ responses related to negative perceptions about euthanasia. Communication and hierarchical problems were the second most reported main category. Nurses were more likely to cite problems with hierarchy than physicians. At the third level, a large percentage of nurses described communication problems with authority and hierarchical problems with physicians. In the same category, physicians were most often concerned with communication problems with patients’ relatives. The ethical problems were reported at different frequencies by physicians and nurses. We asked the participants about ethical decision-making styles. The results show that nurses and physicians do not follow a systematic pattern of ethical decision making. (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)

In lieu of an abstract, here is a brief excerpt of the content:The Ideal of Shared Decision Making Between Physicians and PatientsDan W. Brock (bio)IntroductionShared treatment decision making, with its division of labor between physician and patient, is a common ideal in medical ethics for the physician-patient relationship.1 Most simply put, the physician's role is to use his or her training, knowledge, and experience to provide the patient with facts about the diagnosis and about the prognoses without treatment and with (...) alternative treatments. The patient's role in this division of labor is to provide the values—his or her own conception of the good—with which to evaluate these alternatives, and to select the one that is best for himself or herself. As a rough guide to practice, this is a reasonable conception; most of the time it is likely to produce sound treatment decisions. However, as an ideal it is too simplistic, and is subject to several challenges that I will explore in this paper.Some challenges relate to the physician's role. This facts/values division of labor seems to assume that the physician can and should provide the facts about treatment alternatives in a value-neutral form. But some have questioned whether the sciences on which medicine is based are, or can be, value free. Moreover, the concepts of health and disease, and of the normal and pathological, are held by many to be value laden. And even if it is possible for physicians to provide only value-neutral facts to the patient, should the physicians' role be restricted in this way?Other challenges that I will present in the paper are to the patient's role [End Page 28] as provider of the values for the evaluation of the different treatment alternatives. One defense of this role is based on the claim that physicians are not in a position to know reliably what is in a patient's best interests (Buchanan, forthcoming). I believe at least as influential—even if often not explicitly stated—is an extreme subjectivism about values that assumes that the patient's own ultimate values, which define his or her own conception of the good, are incorrigible. By incorrigible, I mean they cannot be mistaken. In the standard case in which treatment is pursued for the patient's benefit, this extreme subjectivism is thought to support the patient's values guiding treatment decision making and treatment. I will explore this incorrigibility claim and will argue that on each of the main philosophical conceptions of the good for persons it is indefensible and should not be the basis for shared treatment decision making.Underlying this view of the physician-patient division of labor are assumptions and beliefs about the nature and relation of facts and values, and science and ethics, that are largely the legacy of a logical positivism that has long since been rejected by most philosophers. It is time that these unstable foundations for our normative ideal of the physician-patient relation were finally removed and replaced with more defensible underpinnings.Two Models of the Physician-Patient RelationshipPositivists insisted on a relatively sharp distinction between descriptive or empirical claims and science, on the one hand, and evaluative claims and ethics, on the other.2 Descriptive statements and the claims of science were to be true or false according to whether they in fact correctly described and explained the world. By remaining properly descriptive or empirical, science could, at least in principle, be entirely value neutral or value free.In its more extreme versions, positivism held that ethical judgments lacked cognitive content, but were instead expressions of emotions or attitudes, and as such could be neither true nor false, correct or mistaken. Because no evaluative statements were held to be logically entailed by any descriptive or empirical statements, moral reasoning was thought to be properly understood not as reasoning but as attempts at nonrational persuasion.3 Many drew from this an extreme subjectivism in ethics along the lines of what I have called above the incorrigibility thesis—there is no meaningful sense in which an individual's ultimate values defining his or her own conception of the good life could be mistaken, false, or unfounded.These... (shrink)

The aim of the present study was to describe and explore the perception of ethical guidelines and their role in ethical competence-building among Swedish physicians and research nurses. Twelve informants were interviewed in depth. The results demonstrated that the informants had a critical attitude towards ethical guidelines and claimed to make little use of them in practical moral judgements. Ethical competence was seen primarily as character-building, related to virtues such as being empathic, honest and loyal to patients. Ethical competence was (...) assumed to be learned through good examples, role models and practical experience, while ethical guidelines were not perceived as valuable in this process. In order to improve the staff's familiarity with and the usability of ethical guidelines, the workplace needs to provide opportunities for ethical dialogues. In such discussions, argumentation can improve, virtues can be developed and guidelines can be usefully invoked. (shrink)

Garland, Morain, and Sugarman (2023) can be congratulated for their comprehensive and sharp analysis of physicians’ ethical duties with respect to pragmatic clinical trials (PCTs). PCTs embed resea...

The world is experiencing a cataclysmically increasing burden from chronic illnesses. Chronic diseases are on the advance worldwide and treatment strategies to counter this development are dominated by symptom control and polypharmacy. Thus, chronic conditions are often considered irreversible, implying a slow progression of disease that can only be hampered but not stopped. The current plant-based movement is attempting to alter this way of thinking. Applying a nutrition-first approach, the ultimate goal is either disease remission or reversal. Hereby, ethical questions (...) arise as to whether physicians’ current understanding of chronic illness is outdated and morally reprehensible. In this case, physicians may need to recommend plant-based diets to every patient suffering from chronic conditions, while determining what other socioecological factors and environmental aspects play a role in the chronic disease process. This article provides insights to aspects of diet and chronic illness and discusses how the plant-based movement could redefine current understanding of chronic disease. The ethical justifications for recommending of a plant-based diet are analyzed. The article concludes that not advocating for plant-based nutrition is unethical and harms the planet and patients alike. (shrink)

Much of the literature on clinical ethical conflict has been specific to a specialty area or a particular patient group, as well as to a single profession. This study identifies themes of hospital nurses’ and physicians’ clinical ethical conflicts that cut across the spectrum of clinical specialty areas, and compares the themes identified by nurses with those identified by physicians. We interviewed 34 clinical nurses, 10 nurse managers and 31 physicians working at four different Canadian hospitals as part of a (...) larger study on clinical ethics committees and nurses’ and physicians’ use of these committees. We describe nine themes of clinical ethical conflict that were common to both hospital nurses and physicians, and three themes that were specific to physicians. Following this, we suggest reasons for differences in nurses’ and physicians’ ethical conflicts and discuss implications for practice and research. (shrink)

At the conclusion of their 1968 report, the Harvard Ad Hoc Committee argued that “responsible medical opinion” was ready to accept severe and permanent neurologic injury as a new criterion for deat...

In the Netherlands, in 2002, euthanasia became a legitimate medical act, only allowed when the due care criteria and procedural requirements are met. Legally, an Advanced Euthanasia Directive can replace direct communication if a patient can no longer express his own wishes. In the past decade, an exponential number of persons with dementia share a euthanasia request with their physician. The impact this on physicians, and the consequent support needs, remained unknown. Our objective was to gain more insight into the (...) experiences and needs of Dutch general practitioners and elderly care physicians when handling a euthanasia request from a person with dementia. We performed a qualitative interview study. Participants were recruited via purposive sampling. The interviews were transcribed verbatim, and analyzed using the conventional thematic content analysis. Eleven general practitioners and elderly care physicians with a variety of experience and different attitudes towards euthanasia for PWD were included. Euthanasia requests appeared to have a major impact on physicians. Difficulties they experienced were related to timing, workload, pressure from and expectations of relatives, society’s negative view of dementia in combination with the ‘right to die’ view, the interpretation of the law and AEDs, ethical considerations, and communication with PWD and relatives. To deal with these difficulties, participants need support from colleagues and other professionals. Although elderly care physicians appreciated moral deliberation and support by chaplains, this was hardly mentioned by GPs. Euthanasia requests in dementia seem to place an ethically and emotionally heavy burden on Dutch GPs and elderly care physicians. The awareness of, and access to, existing and new support mechanisms needs further exploration. (shrink)

Hunger strikes potentially present a serious challenge for attending physicians. Though rare, in certain cases, a conflict can occur between the obligations of beneficence and autonomy. On the one hand, physicians have a duty to preserve life, which entails intervening in a hunger strike before the hunger striker loses his life. On the other hand, physicians’ duty to respect autonomy implies that attending physicians have to respect hunger strikers’ decisions to refuse nutrition. International medical guidelines state that physicians should follow (...) the strikers’ unpressured advance directives. When physicians encounter an unconscious striker, in the absence of reliable advance directives, the guidelines advise physicians to make a decision on the basis of the patient’s values, previously expressed wishes, and best interests. I argue that if there are no advance directives and the striker has already lost his competence, the physician has the responsibility to resuscitate the striker. Once the striker regains his decision-making capacity, he should be asked about his decision. If he is determined to continue fasting and refuses treatment, the physician has a moral obligation to respect this decisions and follow his advance directives. (shrink)