This book explores the controversial relationship between physicians and the pharmaceutical industry, identifies the ethical tensions and controversies, and proposes numerous reforms both for medicine's own professional integrity and for effective public regulation of the industry.

This article describes the most important determinant of contemporary American medical practice: the corporatization of the health care delivery system. It argues that there is an urgent need for greater reflection by physicians on the values inherent in profit-based health care and on the implications of such a model of care. Other pressures on the medical profession and several available responses are examined. The article then poses a challenge to the profession to assume a more forthright (...) advocacy for social equity in health care provision. (shrink)

That a homosexual -- man or woman -- is neither a sinner nor a sick person is the thesis of this paper by an authority on sexual deviation. Therefore, such a man or woman neither needs penance and pardon nor cure in the medical sense. Nevertheless such individuals sometimes need the help of doctors and must be treated with understanding. The medical profession also has, in the view of the behaviourist school of psychiatrists, of which Dr Bancroft (...) is a member, the duty of influencing social attitudes towards homosexuals. Obviously homosexuals who come into conflict with the law are special cases, and must be treated as such but this is not 'medical' treatment so much as social control even if drugs and other forms of therapy are used. (shrink)

Over the past decades the mortality rate in the United States has decreased and life expectancy has increased. Yet a number of recent studies have drawn Americans attention to the fact that racial and ethnic disparities persist in health care. It is clear that the U.S. health care system is not only flawed for many reasons including basic injustices, but may be the cause of both injury and death for members of racial and ethnic minorities.In 2002, an Institute of Medicine (...) report requested by Congress listed more than 100 studies documenting a wide range of disparities in the United States health care system. This report found that people belonging to racial and ethnic minorities often receive lower quality of health care than do people of European descent, even when their medical insurance coverage and income levels are the same as that of the latter. (shrink)

Review of British Medical Association handbook on human rights and doctors.

The medical profession contains five “spheres of morality”: clinical care, clinical research, scientific knowledge, population health, and the market. These distinct sets of normative commitments require physicians to act in different ways depending on the ends of the activity in question. For example, a physician-scientist emphasizes patients’ well-being in clinic, prioritizes the scientific method in lab, and seeks to maximize shareholder returns as a board member of a pharmaceutical firm. Physicians increasingly occupy multiple roles in healthcare and move (...) between them frequently, creating the possibility of conflict between the ethical obligations of their various roles. This paper examines the entire moral landscape of medicine through the lens of role morality. It develops a novel framework that helps physicians recognize how their moral commitments depend on the nature and context of the situation, clarifies ethical conflicts that physicians face, and concludes with ideas for resolving these conflicts. (shrink)

: Money motivates people, lubricates the movement of resources, mobilizes talent, and breaks down some barriers. But money also has a darker side; it can distract, corrupt, distort, and cruelly exclude. Money is a useful but unruly servant; sometimes, a hard master. The professional, at least in part, belongs to the world of money. We sometimes distinguish the amateur from the professional in that the amateur does it for love; the professional, for money. The professional has one foot in the (...) marketplace, but also, purportedly, professes something else--beyond the bottom line. The following discussion explores the morally complex ties and tensions between money and the medical professions. (shrink)

T. A. Cavanaugh's Hippocrates' Oath and Asclepius' Snake: The Birth of the Medical Profession articulates the Oath as establishing the medical profession's unique internal medical ethic - in its most basic and least controvertible form, this ethic mandates that physicians help and not harm the sick. Relying on Greek myth, drama, and medical experience (e.g., homeopathy), the book shows how this medical ethic arose from reflection on the most vexing medical-ethical problem -- (...) injury caused by a physician -- and argues that deliberate iatrogenic harm, especially the harm of a doctor choosing to kill (physician assisted suicide, euthanasia, abortion, and involvement in capital punishment), amounts to an abandonment of medicine as an exclusively therapeutic profession. The book argues that medicine as a profession necessarily involves stating before others what one stands for: the good one seeks and the bad one seeks to avoid on behalf of the sick, and rejects the view that medicine is purely a technique lacking its own unique internal ethic. It concludes noting that medical promising (as found in the White Coat Ceremony through which U. S. medical students matriculate) implicates medical autonomy which in turn merits respect, including honoring professional conscientious objections. (shrink)

This paper reviews the concept of professional autonomy from anhistorical perspective. It became formalised in the United Kingdom onlyafter a long struggle throughout most of the nineteenth century. In itspure form professional autonomy implies unlimited powers to undertakemedical investigations and to prescribe treatment, irrespective of cost.Doctors alone should determine the quality of care and the levels ofremuneration to which they should be entitled. In the second half of thetwentieth century a steady erosion of professional autonomy occurred inthe United Kingdom. The (...) level of remuneration has been restricted formost doctors for nearly fifty years, whilst the costs of health carehave steadily reduced the doctor's ability to provide unrestricted carewithin the health care system. Reorganisation of the National HealthService in 1983 and 1991 has substantially eroded professional autonomy,to the point where research developments, clinical judgement and ethicalstandards are all now being placed at risk. (shrink)

While there has been much discussion of how the scientific establishment’s culture can engender research misconduct and scientific irreproducibility, this has been discussed much less frequently with respect to the medical profession. Here the authors posit that a lack of self-criticism, an encouragement of novel scientific research generated by the recruitment policies of the UK Royal Training Colleges along with insufficient training in the sciences are core reasons as to why research misconduct and dishonesty prevail within the (...) class='Hi'>medical community. Furthermore, the UK General Medical Council’s own data demonstrates a historic inattentiveness to the ease with which doctors can engage in research misconduct. Suggestions are made as to how these issues can be investigated and alternative incentives for career advancement are adumbrated. (shrink)

This unique textbook utilizes an integrated, case-based approach to explore how the domains of bioethics, public health and the social sciences impact individual patients and populations. It provides a structured framework suitable for both educators (including course directors and others engaged in curricular design) and for medical and health professions students to use in classroom settings across a range of clinical areas and allied health professions and for independent study. The textbook opens with an introduction, describing the intersection of (...) ethics and public health in clinical practice and the six key themes that inform the book's core learning objectives, followed by a guide to using the book. It then presents 22 case studies that address a broad spectrum of patient populations, clinical settings, and disease pathologies. Each pair of cases shares a core concept in bioethics or public health, from community perspectives and end-of-life care to medical mistakes and stigma and marginalization. They engage learners in rigorous clinical and ethical reasoning by prompting readers to make choices based on available information and then providing additional information to challenge assumptions, simulating clinical decision-making. In addition to providing a unique, detailed clinical scenario, each case is presented in a consistent format, which includes learning objectives, questions and responses for self-directed learning, questions and responses for group discussion, references, and suggested further reading. All cases integrate the six themes of patient- and family-centered care; evidence-based practice; structural competency; biases in decision-making; cultural humility and awareness of the culture of medicine; and justice, social responsibility and advocacy. The final section discusses some challenges to evaluating courses and learning encounters that adopt the cases and includes a model framework for learner assessment. (shrink)

The medical profession’s role should be limited to advice and informationThe medical establishment’s desire to interfere with the autonomous wishes of boxers seems at odds with the principle of respect for autonomy prevalent in contemporary biomedical practice. I argue that the role of the medical profession in boxing should be solely an advisory and informational one. In addition, the distinctions made between boxing and other high risk sports often rely on an insufficient knowledge of the (...) sport. This leads to misdirected criticisms and excessive emphasis on the colourful discourse of boxing, as opposed to the practice of boxing itself. Dr Herrera’s claim in his article that boxing differs from other sports in the acceptability of its acts outside the realm of sport is refuted.1 The importance of consent as a legitimising factor is highlighted, and a number of possible solutions to improve safety within the sport are tentatively suggested.In the United Kingdom, a competent adult may legally refuse medical treatment, irrespective of the severity of his condition or the validity of his reasons. With the pre-eminence of an autonomy based model of bioethics, respecting a patient’s wishes forms an integral part of acting in his best interests. It is puzzling, then, to find that the Australian Medical Association have called for a ban on boxing on the grounds that the activity is excessively hazardous to the health of boxers. The often mentioned principle of respect for autonomy is abandoned once the person drops the privileged title of “patient”. This suggests that being a patient …. (shrink)

This is a condensed description of the contents and overarching argument found in Hippocrates’ Oath and Asclepius’ Snake: The Birth of the Medical Profession. In that work, I maintain that the basic medical ethical problem concerns iatrogenic harm. I focus particularly on what I refer to as ‘role-conflation’. This most egregious form of iatrogenic harm occurs when a physician deliberately adopts the role of wounder. A contemporary practice such as physician-assisted suicide exemplifies a doctor’s deliberate wounding. I (...) argue that the author of the Hippocratic Oath – aware of the chronic risk of role-conflation – responds to this threat by having the oath-taker specifically forswear signal acts that wound the sick, such as giving a deadly drug even if asked, giving an abortifacient, sexual predation, and gossiping. I argue that by means of the Oath, Hippocrates founds medicine as a profession, a practice intimately involving promising. (shrink)

Recent studies show that racism still exists in the American medical profession, the fact of which legitimizes the historically long-legacy of mistrust towards medical profession and health authorities among African Americans. Thus, it was suspected that the participation of black patients in end-of-life care has always been significantly low stemmed primarily from their mistrust of the medical profession. On the other hand, much research finds that there are other reasons than the mistrust which makes (...) African Americans feel reluctant to the end-of-life care, such as cultural-religious difference and genuine misunderstanding of the services. If so, two crucial questions are raised. One is how pervasive or significant the mistrust is, compared to the other factors, when they opt out of the end-of-life care. The other is if there is a remedy or solution to the seemingly broken relationship. While no studies available answer these questions, we have conducted an experiment to explore them. The research was performed at two Philadelphia hospitals of Mercy Health System, and the result shows that Black patients’ mistrust is not too great to overcome and that education can remove the epistemic obstacles as well as overcome the mistrust. (shrink)

This paper is a response to a paper by John Coggon ‘Best Interests, Public Interest, and the Power of the Medical Profession'. It argues that certain legal judgements in relation to best interests seek to change and curtail the role of the medical profession in this arena while simultaneously extending the jurisdiction of the courts. It also argues that we must guard against replacing one professional standard, that of the medical profession, with another, that (...) of the judiciary in this area. (shrink)

In responding to my critics, James Childress, Tom Beauchamp, Soren Holm, and Ruth Macklin, I reprise my arguments for medical ethics being an uncommon morality. I also elaborate on points that required further clarification. I explain the role of trust and trustworthiness in the creation of a profession. I also describe my views on the relationship of the medical profession to the society in which medicine is practiced. Finally, I defend my claim that medical ethics (...) “is constructed by medical professionals for medical professionals” by describing the profession’s unique vantage point for regulating and policing the profession’s uncommon powers and privileges. (shrink)

Following the recent condemnation of the National Health Service charging regulations by medical colleges and the UK Faculty of Public Health, we demonstrate that through enactment of this policy, the medical profession is betraying its core ethical principles. Through dissection of the policy using Beauchamp and Childress’ framework, a disrespect for autonomy becomes evident in the operationalisation of the charging regulations, just as a disregard for confidentiality was apparent in the data sharing Memorandum of Understanding. Negative consequences (...) of the regulations are documented to highlight their importance for clinical decision makers under the principles of beneficence and non-maleficence. Exploration of the principle of justice illuminates the core differentiation between the border-bound duties of the State and borderless duties of the clinician, exposing a fundamental tension. (shrink)

What it means to be a medical professional has been defined by medical ethicists throughout history and remains a contemporary concern addressed by this paper. A medical professional is generally considered to be one who makes a public promise to fulfill the ethical obligations expressed in the Hippocratic Code. This presentation summarizes the history of medical professionalism and refocuses attention on the interpersonal relationship of doctor and patient. This keynote address was delivered at the Founders of (...) Bioethics International Congress (June, 2010). (shrink)

Doctors in Denial examines the relationship between the Canadian medical profession and the pharmaceutical industry, and explains how doctors have become dependents of the drug companies instead of champions of patients' health. Big Pharma plays a role in every aspect of doctors' work. These giant, wealthy multinationals influence how medical students are trained and receive information, how research is done in hospitals and universities, what is published in leading medical journals, what drugs are approved, and what (...) patients expect when they go into their doctors' offices. But almost all doctors deny the influence and control the drug companies exert. In this book Dr. Lexchin urges the medical profession to make the changes needed to give priority to protecting and promoting patients' health and benefitting society, rather than enabling Big Pharma to dominate health care while raking in billions in profits from citizens and governments. (shrink)

Is it remarkable that the Royal Dutch Medical Association as a medical professional organization has the point of view that in particular circumstances euthanasia is an acceptable act for a physician. Seen from the viewpoints in the international community, we might say that it is highly remarkable. Frankly put: the RDMA has met strong international disapproval of its standpoint on euthanasia during the last 10 years or so. For instance, the World Medical Association still condemns physicians performing (...) euthanasia as “unethical.” So far the RDMA is the only professional medical organization that holds the view that in particular cases euthanasia is morally acceptable. However, viewed within the context of Dutch society, the Dutch system of healthcare, and the sociocultural approach to moral questions in The Netherlands, the RDMA point of view ceases to be reprehensible. (shrink)

Over the past 50 years, technical advances have taken place in medicine that have greatly increased the possibilities of life-prolonging intervention. The increased possibilities of intervening have brought along new ethical questions. Not everything that is technically possible is appropriate in a specific case: not everything that could be done should be done. In the 1980s, a new term was coined to indicate a class of inappropriate interventions: “medically futile treatment”. A debate followed, with contributions from the USA and several (...) western European countries. A similar debate later took place in Mediterranean countries, although with a different terminology. The purpose of this article is to provide an up-to-date and systematic analysis of the concept of futility, and to draw some conclusions on its operationalisation in medical practice. While the concept of “medical futility” in theory applies to all kinds of medical intervention that might be performed without being medically indicated—things such as certain medical screenings and cosmetic surgery—in practice the literature on “futility” deals only with life-saving and life-sustaining medical interventions. This article deals with this more limited application of the concept of “futility”. (shrink)

When picking up a book titled Licensed to Practice: The Supreme Court Defines the American Medical Profession, one cannot be faulted for expecting a rather dry legal discourse on the Supreme Court case that cemented medical licensure as the norm of American life. James Mohr dispels these expectations from the very first page of the volume. Instead of recitation of legal doctrine, Mohr begins with a murder mystery. While we know from the very first pages the answer (...) to “whodunit,” the rest of the book masterfully explains why they did it. As it turns out, what led to the murder was an intense fight over the proper way to practice medicine. Mohr’s work is.. (shrink)

In 2006, the Chief Medical Officer for England published the report Good Doctors, Safer Patients in a call for strengthened regulation of the medical profession. The changing relationship between patients and doctors in the United Kingdom arises from the interplay between societal expectation and clinical governance, personal formation and professional practice, private being and public doing. The wisdom of professional practice is in the habits of professionals, a practical wisdom that is the reflex of professional identity. Socialization (...) into a profession is the formation of such identity through the legitimate peripheral participation of the apprentice, oriented towards the contingent granting of admission to the community of practice. The conditional nature of continued insider status, permitting members to interact with clients across the professional boundary, is essential to the contract through which the profession enjoys the privileges conferred by society. The governance of the profession is therefore also necessarily circumscribed, a political reality that is currently evidenced in the regulation of medical practice in the United Kingdom. (shrink)

This commentary has three parts. The first one is based on fundamental questions in the field of philosophy of medicine, linked to relevant epistemological and ethical considerations in the analysi...

In the last few years there has been intense debate in Italy on administration of life-prolonging treatment to premature babies at the edge of viability. In 2006, a group of experts based in Florence drafted recommendations known as Carta di Firenze (CdF) for responsible use of intensive care for premature infants between 22 and 25 weeks of gestational age (GA). The CdF was later endorsed by several medicoprofessional associations, but was followed by recommendations by the Ministry of Health mandating resuscitation (...) for all premature babies regardless of GA and parental consent. Recent statements from medicoprofessional bodies seem to show that the ‘always resuscitate rule’ is not supported by many Italian doctors. We argue that ethically sensitive issues in medicine should be regulated with, and not against, the medical profession and its representative bodies. (shrink)

A policy of “preventive detention” has recently been debated in the British Parliament. Alarmed by the high-profile criminal activities of people suspected of having dangerous severe personality disorder , the government have made clear their intention to “indeterminately but reviewably detain” people with DSPD, after diagnosis by forensic psychiatrists, even if the individuals are yet to commit an offence. Such a policy may improve the safety of the public, but has obvious implications for civil liberties. This essay criticises the morality (...) of the government's intention and rejects the notion that the medical profession could ethically collude with such a policy. (shrink)

One of the most significant changes in the medical professions in Europe is the trend towards feminization. Some of the patterns of gender inequality arising from the feminization of the European medical professions are clearly apparent within the Russian medical profession, which experienced feminization 70 years ago. Yet little is known about the processes by which these patterns of gender inequality emerged and were maintained. This article is based on interviews with female doctors in Voronezh, Russia (...) in 1996. It explores the attitudes of these women to gender divisions within the medical profession. This is placed within the wider context of Soviet and post-Soviet employment and family policies directed at women. It is suggested that the material and ideological focus on women’s role in reproduction had direct implications for the choices women made in relation to paid labour. (shrink)

Taking Poland as a case study, this article examines the sociological and historical-institutional factors that determine the relationship between the process of medical professionalisation and reproductive rights in transitional societies. Focusing on three periods in Polish history, (a) Partition era (1772–1918), (b) the Second Polish Republic (1918–1939), and (c) the post-war period (1945–1989), it identifies ruptures and continuities that have shaped the development of the Polish medical profession and its attitude towards abortion care today. Using insights from (...) feminist historical institutionalism, abortion studies, and the sociology of professions, the article applies the concept of ‘dialectical transformations’ to explain institutional and policy reproduction and change over time. It shows how professional and legal institutions are often transferred from one systemic context to another by individuals or organisations whose positions move from opposition to dominance. Understanding such processes is especially important in light of the retrenchment of reproductive rights across the globe. (shrink)

원격의료는 대개 의사와 환자가 떨어져 있는 상태에서 이루어지는 의료 행위 내지 환자와 의사 간의 비대면 의료행위를 지칭하며, 정보통신기술을 매개로 하는 것을 의미한다. 최근 원격의료가 활성화됨에 따라 보건의료 체계는 변화하고 있으며, 그 결과 이로 인해 발생하는 다양한 문제에 대한 신중한 논의가 요청되고 있다. 특히 원격의료 상에서는 컴퓨터를 이용한 의료 정보의 처리가 광범위하게 일어나게 되며, 이에 따라 환자의 의료 정보가 잘못 취급됨으로써 개인 정보 유출 및 사생활 침해 등이 심각한 문제로 떠올랐다. 또한 환자의 치료에 있어 환자와 의사의 신뢰 및 공감 형성이 매우 (...) 중요한 역할을 한다는 점에서 직접적인 대면 관계를 통해 환자에 대한 치료를 도모하지 않고 온라인 장치를 통해 환자와의 관계를 형성하는 원격 의료에서는 전통적인 환자-의사 관계 이상의 신뢰 및 책임감이 요청된다. 이러한 점에서 아리스토텔레스의 프로네시스는 원격의료에서 의료전문직의 실천 원리로서 중요한 의미를 가질 수 있을 것이다. 프로네시스는 훌륭한 행위를 하는 데 필요한 지식으로서의 ‘실천적 지혜’를 의미한다. 따라서 프로네시스는 상황의 특수성 및 개별성에 대한 고려를 바탕으로 보편적인 지식을 활용하여 지금 내가 행동해야 할 행위에 대한 판단을 내리고 지금 이 상황에서 내가 어떻게 행동하는가에 관심을 둔다. 원격의료에서 개별 환자의 다양성과 의료 체계의 복잡성 속에서 의료전문직의 유능함은 과학적인 의학 기술의 습득과 더불어 환자의 상태 및 맥락을 적절하게 해석하는 능력과 여러 가지 대안들 가운데 최선의 치료 행위를 선택하는 통찰력에 달려 있다고 할 수 있을 것이다. 따라서 의료인은 원격의료 시 개별 환자에게 적절한 최선의 치료 행위를 결정하기 위해 구체적인 상황에서 요구하는 특수한 행동 과정을 숙고해야 한다는 점에서 프로네시스는 의료인에게 중요한 실천원리가 된다. (shrink)

In this third article on the role of international comparative practices in the formation of national health care systems I discuss a familiar group of systems-builders--medical professional organisations--and so focus on some early comparisons undertaken by organised groups of doctors. So far in this series I have argued that any attempt to make international comparisons--whether in the 19th-century or today--is bound to be based on a 'characteristically national' understanding. Not infrequently such an understanding finds its clearest expression in the (...) very act of undertaking practical tasks like 'comparing'. Dependent on whether comparisons are carried out by individuals privately, collectively by larger groups within the medical profession, or by government agencies the descriptions of 'national characteristics' (of medical organisation, institutional formation, clinical practice, research, public health and education) will differ in emphasis. -/- The examination of collective professional attempts at international comparison can enhance our understanding of the cultural distinctions that were incorporated by emerging national medical professions. This process can show which aspects of foreign medical systems were deemed pertinent, and also reveals methodology. What did such collective endeavours add to the more biographically coloured comparisons undertaken by the individual mid-century authors I discussed in part II of this series? (shrink)

Patients trust physicians to prescribe based on their fiduciary duty to act in the best interests of their patients, and physicians prescribe based on confidence in research data and clinical guidelines. Recent reports erode confidence in evidence-based medicine. Through self-regulation and a willingness to change, the medical profession can assert its status as a profession distinct from outside influence, serving one interest: the healthcare of patients and the public.

The article presents a doctor–patient relationship model based on the assumptions of a holistic approach to the patient. The author draws attention to selected patients’ needs, ones taken into account in this model. These are the right to autonomy and an individualised approach to the patient. These issues, considered in relation to philosophy, show a conflict between patients’ values and aspirations and doctors’ values and their experience. Nowadays, patients’ needs are protected by consumer rights as well as being strengthened by (...) postmodern philosophy, which shapes society’s awareness of various definitions of health and underlines the right of the individual to self‐determination. This situation creates an incredible challenge for doctors because attempts to assist is, according to medical knowledge, associated with an inevitable collision with the subjective perception of a patient’s health. Because of this issue, the author considers it necessary to enquire about the needs and aspirations of not so much patients as doctors themselves. It is assumed that the definition of what is currently important for this group determines the scope of any possible admission or intentional ignorance of patients’ needs. (shrink)