There is an emerging awareness of the possibility of conflicts of interest in the practice of medicine in Croatia. The paper examines areas within the medical profession where conflicts of interest can and have occurred, probably not only in Croatia. Particularly addressed are situations when a doctor may have dual obligations and how independent ethics committees can help in decreasing the influence of a conflict of interest. The paper also presents extracts from the Croatian Code of Ethics for (...) the medical profession that address problems of conflict of interest. (shrink)

In the United Kingdom (UK), ethical guidance for doctors assumes a therapeutic setting and a normal doctor–patient relationship. However, doctors with dual obligations may not always operate on the basis of these assumptions in all aspects of their role. In this paper, the situation of UK occupational physicians is described, and a set of models to characterise their different practices is proposed. The interaction between doctor and worker in each of these models is compared with the normal doctor–patient (...) relationship, focusing on the different levels of trust required, the possible power imbalance and the fiduciary obligations that apply. This approach highlights discrepancies between what the UK General Medical Council guidance requires and what is required of a doctor in certain roles or functions. It is suggested that using this modelling approach could also help in clarifying the sources of moral conflict for other doctors with “dual obligations” in their various roles. (shrink)

There is an emerging awareness of the possibility of conflicts of interest in the practice of medicine in Croatia. The paper examines areas within the medical profession where conflicts of interest can and have occurred, probably not only in Croatia. Particularly addressed are situations when a doctor may have dual obligations and how independent ethics committees can help in decreasing the influence of a conflict of interest. The paper also presents extracts from the Croatian Code of Ethics for (...) the medical profession that address problems of conflict of interest. (shrink)

Military doctors and nurses, working neither as pure soldiers nor as merely doctors or nurses, may face a ‘role conflict between the clinical professional duties to a patient and obligations, express or implied, real or perceived, to the interests of a third party such as an employer, an insurer, the state, or in this context, military command’. This conflict is commonly called dual loyalty. This chapter gives an overview of the military and the medical ethic and of the (...) resulting dual loyalty problem for medical personnel working in the military. It considers how dual loyalties relate to being a professional, something medical personnel are the paradigmatic examples of, but also something military personnel claim to be. Against that background, the chapter elaborates on the medical rules of eligibility used in Afghanistan, and on the policies concerning military involvement in local healthcare, to see what the existing rules and policies are, and whose interests they serve. (shrink)

How can we ensure that players in the National Football League receive excellent health care they can trust from providers who are as free from conflicts of interest as realistically possible? NFL players typically receive care from the club's own medical staff. Club doctors are clearly important stakeholders in player health. They diagnose and treat players for a variety of ailments, physical and mental, while making recommendations to the player concerning those ailments. At the same time, club doctors have (...) class='Hi'>obligations to the club, namely to inform and advise clubs about the health status of players. While players and clubs share an interest in player health—both of them want players to be healthy so they can play at peak performance—there are several areas where their interests can diverge, and the divergence presents legal and ethical challenges. The current structure forces club doctors to have obligations to two parties—the club and the player—and to make difficult judgments about when one party's interests must yield to another's. None of the three parties involved should prefer this conflicted approach. We propose to resolve the problem of dual loyalty by largely severing the club doctor's ties with the club and refashioning that role into one of singular loyalty to the player-patient. The main idea is to separate the roles of serving the player and serving the club and replace them with two distinct sets of medical professionals: the Players' Medical Staff and the Club Evaluation Doctor. We begin by explaining the broad ethical principles that guide us and that help shape our recommendation. We then provide a description of the role of the club doctor in the current system. After explaining the concern about the current NFL player health care structure, we provide a recommendation for improving this structure. We then discuss how the club medical staff fits into the broader microenvironment affecting player health. (shrink)

This article briefly outlines what the medical duty is, and its special role in international law, before discussing the problems resulting from the dual role as doctor and soldier, which military doctors can expect to meet conceptually, and unfortunately in reality as well. With arguments based on international humanitarian law and ethics, this article shows that greater weight should be given to the medical role.

The doctor-patient relationship -- Consent, choice, and refusal : adults with capacity -- Treating adults who lack capacity -- Children and young people -- Confidentiality -- Health records -- Contraception, abortion, and birth -- Assisted reproduction -- Genetics -- Caring for patients at the end of life -- Euthanasia and physician assisted suicide -- Responsibilities after a patient's death -- Prescribing and administering medication -- Research and innovative treatment -- Emergency situations -- Doctors with dual obligations -- Providing (...) treatment and care in detention settings -- Education and training -- Teamwork, referral, delegation, and shared care -- Public health dimensions of medical practice -- Reducing risk, clinical error, and poor performance. (shrink)

Surgery is the most invasive intervention taken on behalf of health, but significant discrepancies exist between patient expectations and standard operating room practices, especially in teaching institutions. These discrepancies arise from the dual obligations of surgical faculty to present and future patients. On the one hand, in line with a patient’s autonomous election of a procedure and choice of a doctor, faculty are charged with treating patients to the utmost capacity of their knowledge and skill; on the other, (...) in support of a critical community good, they must prepare novice physicians to treat those who will require at least this level of knowledge and skill in the future. Within a broad, contrasting framework of approaches to knowledge, judgment, experience, and nature as described by Hume and Kant, this article explores the complicated concepts of trust, loyalty, assessment, and communications that presently exist between surgical patients, faculty surgeons, and surgical trainees within academic medical centers. (shrink)

Surgery is the most invasive intervention taken on behalf of health, but significant discrepancies exist between patient expectations and standard operating room practices, especially in teaching institutions. These discrepancies arise from the dual obligations of surgical faculty to present and future patients. On the one hand, in line with a patient’s autonomous election of a procedure and choice of a doctor, faculty are charged with treating patients to the utmost capacity of their knowledge and skill; on the other, (...) in support of a critical community good, they must prepare novice physicians to treat those who will require at least this level of knowledge and skill in the future. Within a broad, contrasting framework of approaches to knowledge, judgment, experience, and nature as described by Hume and Kant, this article explores the complicated concepts of trust, loyalty, assessment, and communications that presently exist between surgical patients, faculty surgeons, and surgical trainees within academic medical centers. (shrink)

Military doctors and nurses, employees with a compound professional identity as they are neither purely soldiers nor simply doctors or nurses, face a role conflict between the clinical professional duties to a patient and obligations, express or implied, real or perceived, to the interests of a third party such as an employer, an insurer, the state, or in this context, military command (London et al. 2006). In the context of military medical ethics this is commonly called dual loyalty (...) (or, less commonly, mixed agency). Although other professionals in the military, for instance counsellors or lawyers, might experience similar problems of dual loyalties, it seems that the dual loyalties experienced by military medical personnel are particularly testing. (shrink)

Contexts where the same clinician with an ongoing physician-patient relationship seeks to enroll his or her own patient(s) into a clinical research are ethically tricky due to the associated role c...

In the past decade, the perception of a bioterrorist threat has increased and created a demand on life scientists to consider the potential security implications of dual use research. This article examines a selection of proposed moral obligations for life scientists that have emerged to meet these concerns and the extent to which they can be considered reasonable. It also describes the underlying reasons for the concerns, how they are managed, and their implications for scientific values. Five criteria (...) for what constitutes preventable harm are suggested and a number of proposed obligations for life scientists are considered against these criteria, namely, the obligations to prevent bioterrorism; to engage in response activities; to consider negative implications of research; not to publish or share sensitive information; to oversee and limit access to dangerous material; and to report activities of concern. Although bioterrorism might be perceived as an imminent threat, the analysis illustrates that this is beyond the responsibility of life scientists either to prevent or to respond to. Among the more reasonable obligations are duties to consider potential negative implications of one's research, protect access to sensitive material, technology and knowledge, and report activities of concern. Responsibility, therefore, includes obligations concerned with preventing foreseeable and highly probable harm. A central conclusion is that several of the proposed obligations are reasonable, although not unconditionally. (shrink)

Glenn Cohen, Holly Fernandez Lynch, and Christopher Deubert are right in their article “A Proposal to Address NFL Club Doctors’ Conflicts of Interest and to Promote Player Trust” that the problem with the medical care rendered to National Football League players is not that the doctors are bad, but that the system in which they provide care is structured badly. We saw some of the problems this system causes last season in what happened to Case Kenum, a quarterback for the (...) Los Angeles Rams who, despite having a possible concussion from a game injury, was allowed to continue to play, with a concussion spotter in the booth and coaches, teammates, seven game officials, and two full training staffs present. From my experience playing in the league from 1989 to 1999, I do not believe that you can eliminate the conflict of interest completely, but I think it can be limited to the point that it does not harm the player. As the structure is now, with the team paying the club doctor, it is impossible to put the players’ health and well-being before the team's on-field priorities. (shrink)

Inadequate diet is the leading risk factor for morbidity and mortality worldwide. However, approaches to identifying inadequate diets in clinical practice remain inconsistent, and dietary interventions frequently focus on facilitating ‘healthy choices’, with limited emphasis on structural constraints. We examine the ethical implications of introducing a routine question in the medical history about ability to access food. Not collecting data on food security means that clinicians are unable to identify people who may benefit from support on an individual level, unable (...) to consider relevant dietary risk factors for disease and disease progression and unable to monitor population trends and inequalities in dietary access in order to design effective policy interventions. We argue that the current lack of routine screening for food insecurity is inconsistent with our approach to other health behaviours, as well as with doctors’ frequent informal role as gatekeepers to the food aid system, and recent calls for governmental action on food insecurity and health inequalities from individual clinicians and professional bodies. Potential ethical barriers to asking patients about food security are addressed, including concerns about stigma, limiting autonomy, fair resource allocation, unclear professional remits and clinicians’ ability to offer effective interventions. We suggest that there is an ethical imperative for doctors to ask patients about their ability to access healthy food. Gathering this data provides a valuable first step in re-framing the social determinants of health as modifiable risks, rather than inevitable inequities. No data are available. (shrink)

Background Post-September 11, 2001, the U.S. government has labeled thousands of Afghan war detainees "unlawful combatants". This label effectively deprives these detainees of the protection they would receive as "prisoners of war" under international humanitarian law. Reports have emerged that indicate that thousands of detainees being held in secret military facilities outside the United States are being subjected to questionable "stress and duress" interrogation tactics by U.S. authorities. If true, American military physicians could be inadvertently becoming complicit in detainee abuse. (...) Moreover, the American government's openly negative views towards such detainees could result in military physicians not wanting to provide reasonable care to detainees, despite it being their ethical duty to do so. Discussion This paper assesses the physician's obligations to treat war detainees in the light of relevant instruments of international humanitarian law and medical ethics. It briefly outlines how detainee abuse flourished in apartheid South Africa when state physicians became morally detached from the interests of their detainee patients. I caution U.S physicians not to let the same mindset befall them. I urge the U.S. medical community to advocate for detainee rights in the U.S, regardless of the political culture the detainee emerged from. I offer recommendations to U.S physicians facing dual loyalty conflicts of interest in the "war on terror". Summary If U.S. physicians are faced with a conflict of interest between following national policies or international principles of humanitarian law and medical ethics, they should opt to adhere to the latter when treating war detainees. It is important for the U.S. medical community to speak out against possible detainee abuse by the U.S. government. (shrink)

Background Post-September 11, 2001, the U.S. government has labeled thousands of Afghan war detainees "unlawful combatants". This label effectively deprives these detainees of the protection they would receive as "prisoners of war" under international humanitarian law. Reports have emerged that indicate that thousands of detainees being held in secret military facilities outside the United States are being subjected to questionable "stress and duress" interrogation tactics by U.S. authorities. If true, American military physicians could be inadvertently becoming complicit in detainee abuse. (...) Moreover, the American government's openly negative views towards such detainees could result in military physicians not wanting to provide reasonable care to detainees, despite it being their ethical duty to do so. Discussion This paper assesses the physician's obligations to treat war detainees in the light of relevant instruments of international humanitarian law and medical ethics. It briefly outlines how detainee abuse flourished in apartheid South Africa when state physicians became morally detached from the interests of their detainee patients. I caution U.S physicians not to let the same mindset befall them. I urge the U.S. medical community to advocate for detainee rights in the U.S, regardless of the political culture the detainee emerged from. I offer recommendations to U.S physicians facing dual loyalty conflicts of interest in the "war on terror". Summary If U.S. physicians are faced with a conflict of interest between following national policies or international principles of humanitarian law and medical ethics, they should opt to adhere to the latter when treating war detainees. It is important for the U.S. medical community to speak out against possible detainee abuse by the U.S. government. (shrink)

Do facts about what an agent would freely do in certain circumstances at least partly determine any of her moral obligations? Actualists answer ‘yes’, while possibilists answer ‘no’. We defend two novel hybrid accounts that are alternatives to actualism and possibilism: Dual Obligations Hybridism and Single Obligation Hybridism. By positing two moral ‘oughts’, each account retains the benefits of actualism and possibilism, yet is immune from the prima facie problems that face actualism and possibilism. We conclude by (...) highlighting one substantive difference between our two hybrid accounts. (shrink)

This comment on the case presented in ‘Cholera and Nothing More’ argues that the physicians at this public-health centre did not have an ordinary clinician's obligations to promote the health of the people who came to them for care, as they were instead set up to serve a laudable and urgent public-health goal, namely, controlling a cholera outbreak. It argues that, nonetheless, these physicians did have some limited moral duties to care for other diseases they encountered—some ancillary-care duties—arising from (...) their voluntarily entering into a kind of intimate relationship with the patients they took in, one in which those patients effectively waive certain rights to bodily and medical privacy. (shrink)

As an employee, a sports doctor has obligations to their employer, but also professional and widely accepted obligations of a doctor to the patient . The conflict is evident when sports doctors are asked by an athlete to keep personal health information confidential from the coach and team management, and yet both doctor and athlete have employment contracts specifying that such information shall be shared. Recent research in New Zealand shows that despite the presence of an employment contract, (...) there appears to be a wide range of behaviours among sports doctors when an athlete requests that information about them be kept from team management. Many seem willing to honour requests to keep health information about the athlete confidential, thereby being in breach of the employment contract, while others insist on informing team management against the wishes of the athlete. There are a number of potential solutions to this dilemma from forcing doctors to meet their contractual obligations, to limiting the expectations of the employment contract. This paper suggests that at times it may be appropriate to do both, making the position of the doctor clearer and supporting the ability of this group to resist pressure by coaches and management through having a robust code of ethics. (shrink)

Doctors form an essential part of an effective response to the COVID-19 pandemic. We argue they have a duty to participate in pandemic response due to their special skills, but these skills vary between different doctors, and their duties are constrained by other competing rights. We conclude that while doctors should be encouraged to meet the demand for medical aid in the pandemic, those who make the sacrifices and increased efforts are owed reciprocal obligations in return. When reciprocal (...) class='Hi'>obligations are not met, doctors are further justified in opting out of specific tasks, as long as this is proportionate to the unmet obligation. (shrink)

Patients sometimes request procedures their doctors find morally objectionable. Do doctors have a right of conscientious refusal? I argue that conscientious refusal is justified only if the doctor's refusal does not make the patient worse off than she would have been had she gone to another doctor in the first place. From this approach I derive conclusions about the duty to refer and facilitate transfer, whether doctors may provide 'moral counseling,' whether doctors are obligated to provide objectionable procedures when no (...) other doctor is available, why the moral consensus among doctors seems relevant even though it does not determine whether something is morally acceptable, and whether doctors should stay out of fields whose standard procedures they find morally unacceptable. (shrink)

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

The concept of dual-use encapsulates the potential for well-intentioned, beneficial scientific research to also be misused by a third party for malicious ends. The concept of dual-use challenges scientists to look beyond the immediate outcomes of their research and to develop an awareness of possible future (mis)uses of scientific research. Since 2001 much attention has been paid to the possible need to regulate the dual-use potential of the life sciences. Regulation initiatives fall under two broad categories—those that (...) develop the ethical education of scientists and foster an awareness and responsibility of dual-use issues, and those which assess the regulation of information being generated by current research. Both types of initiatives are premised on a cautious, risk-adverse philosophy which advocates careful examination of all future endpoints of research endeavors. This caution advocated within initiatives such as pre-publication review of journal articles contrasts to the obligation to share underpinning data sharing discussions. As the dual-use debate has yet to make a significant impact on data sharing discussions (and vice versa) it is possible that these two areas of knowledge control may present areas of ethical conflict for scientists, and thus need to be more closely examined. This paper examines the tension between the obligation to share exemplified by data sharing principles and the concerns raised by the risk-cautious culture of the dual-use debates. The paper concludes by reflecting on the issues of responsibility as raised by dual-use as relating to data sharing, such as the chain of custody for shared data. (shrink)

In this article I propose an original view of the nature of shared intention. In contrast to psychological views (Bratman, Searle, Tuomela) and normative views (Gilbert), I argue that both functional roles played by attitudes of individual participants and interpersonal obligations are factors of central and independent significance for explaining what shared intention is. It is widely agreed that shared intention (I) normally motivates participants to act, and (II) normally creates obligations between them. I argue that the view (...) I propose can explain why it is not a mere accident that both (I) and (II) are true of shared intention, while psychological and normative views cannot. The basic idea is that shared intention involves a structure of attitudes of individuals –including, most importantly, attitudes of reliance – which normally plays the relevant motivating roles and creates the relevant obligations. (shrink)

Do doctors and other medical staff have an obligation to treat those who need their help? This paper assumes no legal or contractual obligations but attempts to discover whether there is any general moral obligation to treat those in need. In particular the questions of whether or not the obligation that falls on medical staff is different from that of others and of whether doctors are more blameworthy than others if they fail to treat patients are examined. Finally we (...) look at the question of the burden of this obligation and at the responsibility of society to mitigate its hardships. (shrink)

Doctors are increasingly enjoined by their professional organisations to involve themselves in supraclinical advocacy, which embraces activities focused on changing practice and the system in order to address the social determinants of health. The moral basis for doctors’ decisions on whether or not to do so has been the subject of little empirical research. This opportunistic qualitative study of the values of medical graduates associated with the Sydney Medical School explores the processes that contribute to doctors’ decisions about taking up (...) the advocate role. Our findings show that personal ideals were more important than professional commitments in shaping doctors’ decisions on engagement in advocacy. Experiences in early life and during training, including exposure to power and powerlessness, significantly influenced their role choices. Doctors included supraclinical advocacy in their mature practices if it satisfied their desire to achieve excellence. These findings suggest that common approaches to promoting and facilitating advocacy as an individual professional obligation are not fully congruent with the experiences and values of doctors that are significant in creating the advocate. It would seem important to understand better the moral commitments inherent in advocacy to inform future developments in codes of medical ethics and medical education programs. (shrink)

Humanity entered the twenty-first century with revolutionary achievements in biomedical research. At the same time multiple “dual-use” results have been published. The battle against infectious diseases is meeting new challenges, with newly emerging and re-emerging infections. Both natural disaster epidemics, such as SARS, avian influenza, haemorrhagic fevers, XDR and MDR tuberculosis and many others, and the possibility of intentional mis-use, such as letters containing anthrax spores in USA, 2001, have raised awareness of the real threats. Many great men, including (...) Goethe, Spinoza, J.B. Shaw, Fr. Engels, J.F. Kennedy and others, have recognized that liberty is also a responsibility. That is why the liberty to decide now represents an acknowledged necessity: biomedical research should be supported, conducted and published with appropriate measures to prevent potential “dual use”. Biomedical scientists should work according to the ethical principles of their Code of Conduct, an analogue of Hippocrates Oath of doctors; and they should inform government, society and their juniors about the problem. National science consulting boards of experts should be created to prepare guidelines and control the problem at state level. An international board should develop minimum standards to be applicable by each country. Bio-preparedness is considered another key-measure. (shrink)

There is a growing belief in the US that medicine is an altruistic profession, and that physicians display altruism in their daily work. We argue that one of the most fundamental features of medical professionalism is a fiduciary responsibility to patients, which implies a duty or obligation to act in patients' best medical interests. The term that best captures this sense of obligation is “beneficence”, which contrasts with “altruism” because the latter act is supererogatory and is beyond obligation. On the (...) other hand, we offer several examples in which patients act altruistically. If it is patients and not the doctors who are altruistic, then the patients are the gift-bearers and to that extent doctors owe them gratitude and respect for their many contributions to medicine. Recognising this might help us better understand the moral significance of the doctor-patient relationship in modern medicine. (shrink)

Advance directives have been lauded by scholars and supported by professional organizations, Congress, and the United States Supreme Court. Despite this encouragement, only a small number of capable patients execute living wills or appoint health care agents. When patients do empower proxies, doctors may be uncertain about the scope of their duties and obligations to these persons who, in theory, stand in the shoes of the patient. This article argues for a conscious focus on the ethical duties, emotional supports, (...) and guidance owed by physicians to health care agents. (shrink)

It is argued that promissory obligation arising from the contract of employment offers a simpler and less contentious explanation and justification of the doctor-nurse relationship at work, than does May's proposal of second-order reasons. The second-order reason position is rejected as the norm for that relationship, and in the exceptional case, where it is admitted, shared employee status is identified as primary validator of a doctor as locus of rational authority. Finally, a brief case is made for a more precise (...) vocabulary to describe the doctor-nurse relationship, as a contribution to more collegial relations. (shrink)

Artificial intelligence (AI) based clinical decision support systems (CDSS) are becoming ever more widespread in healthcare and could play an important role in diagnostic and treatment processes. For this reason, AI‐based CDSS has an impact on the doctor–patient relationship, shaping their decisions with its suggestions. We may be on the verge of a paradigm shift, where the doctor–patient relationship is no longer a dual relationship, but a triad. This paper analyses the role of AI‐based CDSS for shared decision‐making to (...) better comprehend its promises and associated ethical issues. Moreover, it investigates how certain AI implementations may instead foster the inappropriate paradigm of paternalism. Understanding how AI relates to doctors and influences doctor–patient communication is essential to promote more ethical medical practice. Both doctors' and patients' autonomy need to be considered in the light of AI. (shrink)

A murder case that had some features in common with the Tarasoff case occurred in Sasebo City, Japan, in 2014. A 15-year-old high school girl was murdered and her 16-year-old classmate was arrested on suspicion of homicide. One and a half months before the murder, a psychiatrist who had been examining the girl called a prefectural child consultation centre to warn that she might commit murder, but he did not reveal her name, considering it his professional duty to keep it (...) confidential. Article 134 of the Japanese Criminal Law states that doctors should not disclose patient information obtained in clinical practice without a legitimate reason, but the Japanese Supreme Court has not specified what constitutes a legitimate reason. Mass media and commentators suggested that the murder could have been prevented if the psychiatrist had disclosed the girl's name to the authorities or had isolated her coercively in a psychiatric ward. However, the authors disagree with such claims. This article discusses obligations imposed on concerned individuals and third party members in cases involving ethical dilemmas regarding patient confidentiality and information disclosure. It is concluded that everyone should fulfill their obligations to prevent such tragedies and one should judge the appropriateness of others’ actions based not on the consequences of their actions, but on the processes used to decide on a course of action and their commitment. It is necessary for us to establish a society in which concerned parties can do what they think is ethically best without fearing ungrounded charges. (shrink)

Much has been written by many distinguished persons about the philosophical, religious and ethical considerations of doctors and their involvement with torture. What follows will not have the erudition or authority of the likes of St Augustine, Mahatma Gandi, Schopenhauer or Thomas Paine. It represents the views of a very ordinary person; a presumption defended by the submission that many very ordinary persons have been, and will be, instruments for effecting, assisting or condoning the physical or mental anguish of others. (...) As practitioners of medicine, we are particularly vulnerable, since our particular knowledge and our privileged position may be so easily abused--to the detriment of others. Those of us who practice clinical forensic medicine have even greater responsibility by virtue of our daily contact with the enforcement of law, criminal procedure, and the machinations of the judiciary. We are thus particularly well placed to monitor, encourage or discourage the occurrence of evil practices within the community. It is imperative, therefore, that the ordinary doctor should be cognisant of, and be party to, a code of conduct formulated by his peers and having reference to his obligations as a citizen, and doctor, and to his ability to manipulate human activity. Forensic physicians have further discretionary powers as arbiters in the marriage of the art and ethics of healing with the principles and practice of justice. (shrink)

There are a range of ethical issues that confront physicians in times of war, as well as some of the uses of physicians during wars. This book presents a theoretical apparatus which undergirds those debates, namely by casting physicians as being confronted with dual-loyalties during times of war. While this theoretical apparatus has already been developed in other contexts, it has not been specifically brought to bear on the ethical conflicts that attain in wars. Arguably, wars thrust physicians into (...) ethical conflicts insofar as these wars create a tension between a physician's obligation to heal and an obligation to serve some other good (e.g., military chain of command, national security, the greater good, etc.). Alternatively, we can debate whether this conception is appropriate. For example, one could argue that that non-medical duties cannot attach to physicians (e.g., due to nonoverlapping spheres of justice), thus abrogating the dual-loyalty challenge. Or else one could argue that these medically-trained personnel do not act qua physicians at all (but rather partisan advocates) and therefore duties that would otherwise attach to physicians do not attach here. In the first part of this book, these issues are debated. In the second part of the book, the dual-loyalities frame is used to explore various substantive debates that obtain when the military makes use of physicians. Physician involvement in torture is a heated topic, and certainly the most visible element of the debate. Also, however, we could use the dual-loyalties framework to explore issues in other arenas, such as: development of chemical and biological weapons, medical neutrality/battlefield triage, and so on. In each of these cases, the same tensions arguably exist: physicians have duties both to their patients and elsewhere (which, depending on the details of the view, could be any of the above-mentioned ends). (shrink)

Informed consent to medical intervention is fundamental in both ethics and law. But in practice it is often not taken seriously in developing countries. This paper provides an appraisal of informed consent practices in Bangladesh. Following a review of the ethical and legal principles of informed consent, it assesses the degree to which doctors adhere to it in Bangladesh. Based on findings of non-compliance, it then investigates the reasons for such non-compliance through an appraisal of informed consent practices in Bangladesh (...) and provides recommendations aimed at improving such practices. The significance of this paper lies in unveiling the interdependence between the ethical and legal traits of informed consent and their ramifications on strengthening the patient-oriented approach of duty to care. (shrink)

A UK doctor was recently acquitted of charges of reinstating a variety of female genital mutilation after delivering a child. In this paper, I contend that this incident reflects a broader confusion concerning the ethico-legal status of non-therapeutic genital surgeries for children and adults, which are not derivable from tenets of medical ethics, but rather violate them. I argue that medical professionals have an obligation to announce and address this confusion in order to motivate legislative reform, since the inconsistency of (...) the current law entrenches the underlying sexism and ethnocentrism upon which its sense depends. Without convincing arguments for condoning male circumcision and female cosmetic genital surgery and for treating adult women of colour as lacking the capacity to consent, the current legislation stands in need of urgent revision. (shrink)

BackgroundSimilar to many other countries, in Germany patients with alcohol-related liver disease are obliged to prove their abstinence before being accepted on a waitlist for liver transplantation. Health care professionals (HCPs) must both treat patients and ensure that patients have proven their abstinence. The aim of this exploratory study was to develop a deeper understanding of how HCPs deal with this dual role.MethodsThe study used semi-structured interviews as the source of data. 11 healthcare professionals from ten of the 22 (...) German transplant centers were interviewed. After transcription, a qualitative content analysis was performed.ResultsWe found that these HCPs faced an ethical dilemma, as they must balance the roles of being both a treatment provider (the therapist role) and an assessor (the monitoring role). To solve this dilemma, the strategy seems to be a tendency for the HCPs to take on one dominant role amongst these two roles. HCPs who prefer to take on the therapist role seem to feel burdened by the 6-month abstinence rule and the obligation to monitor their patients. HCPs who prefer to take on the monitoring role tend to have negative assumptions about the patients. HCPs also reported the impression that patients perceive HCPs as more involved in monitoring and less open to the therapeutic role. From this it can be deduced that current regulations and structures lead both to stress for HCPs and to suboptimal therapy for those affected.ConclusionsThe results showed that current transplantation guidelines can have a negative impact on both patient care and the burdens on the HCPs. From our point of view, there are various changes that could be made to the current clinical practice that would help solve this dilemma. For instance, integrating other assessment criteria that are more closely adapted to the health status trajectory and psychosocial background of the individual patient would be both possible and would lead to improvements in practice. (shrink)

When weighing up which inhaler to prescribe, a doctor may prioritise a patient’s preferences over the expected harms from the associated carbon emissions. Parker argues that this is wrong.1 Doctors have a pro-tanto duty to switch from a high-carbon metered-dose inhaler (MDI) to a low-carbon dry-powdered inhaler (DPI)—even though this provides no direct patient benefit—unless switching would undermine trust or significantly worsen a patient’s health. He goes on to state that even if DPIs are more expensive for the National Health (...) Service (NHS) then this is justified so long as it does not ‘significantly threaten’ the NHS’ ability to protect and promote health. This may appear to be a radical proposal, challenging the ethical principles of autonomy, health entitlements and justly distributed resources. However, we will claim that it is only radical in so far as one perceives (A) patient autonomy and healthcare entitlements as existing within a vacuum, unrelated to other foundational ethics concerns and (B) the health consequences of a given healthcare budget are limited solely to the designated recipients rather than all affected parties. Here, we test the claim that our responsibility for promoting patient autonomy …. (shrink)

Wars must be won if our country … is to be protected from unthinkable outcomes, as the events on September 11th most recently illustrated…. This best protection unequivocally requires armed forces having military physicians committed to doing what is required to secure victory…. As opposed to needing neutral physicians, we need military physicians who can and do identify as closely as possible with the military so that they, too, can carry out the vital part they play in meeting the needs (...) of the mission.Counterpoint:We believe the role of the “physician–soldier” to be an inherent moral impossibility because the military physician, in an environment of military control, is faced with the difficult problems of mixed agency that include obligations to the “fighting strength” and … “national security.”. (shrink)

The process of obtaining informed consent in a teaching hospital in a developing country (e.g. Nigeria) is shaped by factors which, to the Western world, may be seen to be anti-autonomomous: autonomy being one of the pillars of an ideal informed consent. However, the mix of cultural bioethics and local moral obligation in the face of communal tradition ensures a mutually acceptable informed consent process. Paternalism is indeed encouraged by the patients who prefer to see the doctor as all-powerful and (...) all-knowing, and this is buttressed by the cultural practice of customary obedience to those ‘above you’: either in age or social rank. The local moral obligation reassures the patients that those in authority will always look after others placed in their care without recourse to lengthy discussions or signed documentation, while the communal traditions ensure that the designated head of a family unit has the honor and sole responsibility of assenting and consenting to an operation to be carried out on a younger, or female, member of the family. Indeed it is to only a few educated patients that the informed consent process is deemed a shield against litigation by the doctors. This paper later addresses the need for physicians to update their knowledge on the process of informed consent through the attendance of biomedical ethics courses, which should highlight socio-cultural practices that may make this process different from the Western concept, but perfectly acceptable in this setting. (shrink)

The process of obtaining informed consent in a teaching hospital in a developing country (e.g. Nigeria) is shaped by factors which, to the Western world, may be seen to be anti‐autonomomous: autonomy being one of the pillars of an ideal informed consent. However, the mix of cultural bioethics and local moral obligation in the face of communal tradition ensures a mutually acceptable informed consent process. Paternalism is indeed encouraged by the patients who prefer to see the doctor as all‐powerful and (...) all‐knowing, and this is buttressed by the cultural practice of customary obedience to those ‘above you’: either in age or social rank. The local moral obligation reassures the patients that those in authority will always look after others placed in their care without recourse to lengthy discussions or signed documentation, while the communal traditions ensure that the designated head of a family unit has the honor and sole responsibility of assenting and consenting to an operation to be carried out on a younger, or female, member of the family. Indeed it is to only a few educated patients that the informed consent process is deemed a shield against litigation by the doctors. This paper later addresses the need for physicians to update their knowledge on the process of informed consent through the attendance of biomedical ethics courses, which should highlight socio‐cultural practices that may make this process different from the Western concept, but perfectly acceptable in this setting. (shrink)

Doctor Marti is to be commended for compressing such a rich variety of historical reminders and flashes of philosophical insight within the scope of his brief and suggestive paper. Among the important reminders culled from the tradition are, first of all, the pivotal importance of St. Augustine’s fusion of philosophical inwardness and Christian doctrine, then a correct and careful estimation of Kant’s location of the ethically active self within the noumenal order, and finally a lucid synthesis of Schelling’s insights into (...) the possibility of a philosophical religion. Marti understands that to repeat the tradition philosophically is to renew and restore it. But he also brings novel insights to bear upon the Kantian-Hegelian tradition, the most striking of which are the assertions that the work of ratiocination is guesswork, and that obligation becomes objective only in and with the act of taking responsibility. Each of these gems deserves to be cut, polished, and set within its own extended treatment. (shrink)

Religious considerations and language do not typically belong in the professional advice rendered by a doctor to a patient. Among the rationales mounted by Greenblum and Hubbard in support of that conclusion is that religious considerations and language are incompatible with the role of doctors as public officials.1 Much as I agree with their conclusion, I take issue with this particular aspect of their analysis. It seems based on a mischaracterisation of what societal role doctors fulfil, qua doctors. What obliges (...) doctors to communicate by means of content that is expressed in public reason-based language is not that they are public officials. Doctors as doctors are not necessarily public officials. Rather, doctors have such obligations, because they are professionals. Unlike public officials doctors are part of a profession that is to a significant extent self-governing. This holds true for all professions. The …. (shrink)

Common morality has been the touchstone of medical ethics since the publication of Beauchamp and Childress's Principles of Biomedical Ethics in 1979. Rosamond Rhodes challenges this dominant view by presenting an original and novel account of the ethics of medicine, one deeply rooted in the actual experience of medical professionals. She argues that common morality accounts of medical ethics are unsuitable for the profession, and inadequate for responding to the particular issues that arise in medical practice. Instead, Rhodes argues that (...) medicine's distinctive ethics should be explained in terms of the trust that society allows to the profession. Trust is the core and starting point of Rhodes' moral framework, which states that the most basic duty of doctors0is to "seek trust and be trustworthy." 0Building from this foundation, Rhodes explicates the sixteen specific duties that doctors take on when they join the profession, and demonstrates how her view of these duties is largely consistent with the codes of medical ethics of medical societies around the world. She then explains why it is critical for physicians to develop the attitudes or "doctorly" virtues that comprise the character of trustworthy doctors and buttress physicians' efforts to fulfil their professional obligations. Her book's presentation of physicians' duties and the elements that comprise a doctorly character, together add up to a cohesive and comprehensive description of what medical professionalism really entails. Rhodes's analysis provides a clear understanding of medical professionalism as well as a guide for doctors navigating the ethically challenging situations that arise in clinical practice. (shrink)

The advent of personal genomics companies offering direct translation of scientific data into personal health information, calls into question traditional policies to refuse disclosure of such scientific data to research participants. This seems especially true for population biobanks, as they collect not only genotype information but also associated phenotype information, and thus may be in a unique position to translate their scientific findings into personal health information for their participants. Disclosure of such information seems mandated by the expectations raised by (...) biobanks and their participants' rights to know health information, to know clinical research results, to life and health and particularly their right to benefit. Refusals to disclose such information can be grounded in the lack of analytical validity and/or clinical utility of most findings, the need to avoid the therapeutic misconception, the complexity and costs involved in translation and disclosure and the disproportionate burden resulting from the obligation to respect participants' right not to know before any disclosure can be made. Currently, any demands by participants in population biobanks for full disclosure of all pertinent personal health information potentially resulting from the biobank's scientific findings are unlikely to be granted by a Dutch court under Dutch and international law. As the law stands now, a population biobank is neither a doctor nor a personal genomics company. However, in view of the rapid scientific, medical, technological, commercial and social developments, population biobanks must prepare to take more care of their participants' legitimate interest in receiving as much validated personal health information as reasonably possible, in a timely fashion, by developing appropriate translation and disclosure mechanisms. This paper examines whether population biobank participants have the right, under Dutch civil law and international law, to full disclosure, i.e. to all information generated by the biobank that is pertinent to their present and future health. It pioneers the format of a hypothetical court case to elucidate the legal and policy arguments" for and against full disclosure. (shrink)

In the first part of the paper, the author discusses the origin and obligation of the medical profession and argues that the duty of fidelity in the context of a patient–professional relationship (PPR) is the central obligation of medical professionals. The duty of fidelity entails seeking the patient’s best interests even at the expense of the professional’s own, and refusing to treat a risk-patient infected by SARS is a breach of fidelity because the medical professional is involved in a situation (...) of conflict of interests and places his/her own health interests ahead of the patient. The author attributes the failure to the fact that professional ethical codes are not legally enforceable, and this failure at the microethical level damages the integrity of the profession at the macroethical level. The author argues that professional autonomy must be subordinated to professional fidelity for the medical profession to survive as a social institution. In the second part of the paper, the author shows that the PPR has most of the important attributes of a fiduciary relationship, and analyzes several important court cases in some common law jurisdictions to illustrate the increasing importance of fiduciary law in adjudicating disputes between patients and medical professionals, and appeals to law courts and legislatures to apply more stringent fiduciary principles on the medical profession to ensure that the professional duty of fidelity is enforced and the goal of medicine fulfilled for the interests of members of the community who has established the medical profession in the first place. (shrink)