Doctors and patients: Partners or adversaries?

The author suggests that an inadequate understanding of the ethical relationship between doctors and patients is at the core of many current health care issues. The doctor-patient relationship is discussed with an emphasis on the expectations of patients and physicians. Three sets of expectations or models of doctor-patient interaction are reviewed and a number of health care issues are explored in this frame-work. It is hypothesized that when doctors and patients have similar expectations they will be partners and that when they differ, they are more likely to be adversaries. Finally it is suggested that unless national health policy is designed to take into account the effect of legislation on physicians' and patients' expectations, dissatisfaction with health care will continue to increase.     

How to justify enforcing a Ulysses contract when Ulysses is competent to refuse

Sometimes the mentally ill have sufficient mental capacity to refuse treatment competently, and others have a moral duty to respect their refusal. However, those with episodic mental disorders may wish to precommit themselves to treatment, using Ulysses contracts known as "mental health advance directives." How can health care providers justify enforcing such contracts over an agent's current, competent refusal? I argue that providers respect an agent's autonomy not retrospectively--by reference to his or her past wishes-and not merely synchronically--so that the agent gets what he or she wants right now-but diachronically and prospectively, acting so that the agent can shape his or her circumstances as the agent wishes over time, for the agent will experience the consequences of providers' actions over time. Mental health directives accomplish this, so they are a way of respecting the agent's autonomy even when providers override the agent's current competent refusal.     

Just health care (I): Is beneficence enough?

Few in our society believe that access to health care should be determined primarily by ability to pay. We believe instead that society has an obligation to assure access to adequate health care for all. This is the view explicitly endorsed in the President's Commission Report Securing Access to Health Care. But there is an important moral ambiguity here, for this obligation may be construed as being either beneficence-based or justice-based. A beneficience-based construal would yield a much weaker obligation with respect to the distribution of health care. In the first section of this paper I argue that the President's Commission is committed only to this weaker construal of this obligation. In the second section I argue that such a beneficence-based obligation is really rooted in a libertarian conception of justice, similar to that recently articulated by Engelhardt, and that this conception is seriously flawed when it comes to effecting a just distribution of health care.     

Attitudes to doctors and medicine: The preliminary development of a new scale

Abstract

The preliminary development of a new scale to measure attitudes towards medicine and doctors is described. The scale comprises four factors: “positive attitude towards doctors,” “positive attitude towards medicine,” “negative attitude towards doctors,” and “negative attitude towards medicine.” Alpha coefficients for the four scales were satisfactory, ranging from 0.69 to 0.76. Test re-test reliabilities ranged from 0.69 to 0.81. Evidence of criterion-related validity was obtained from comparison of the attitudes of five groups involved in health care: nurses, medical students, patients, and sociologists and psychologists who are teachers in medical schools. Patients and medical students held significantly more positive attitudes towards doctors and medicine that did nurses and behavioural scientists. While nurses were as negative towards doctors as sociologists and psychologists, they were significantly less negative about medicine.     

Talking to primary care patients about weight: a study of GPs and practice nurses in the UK

Evidence-based guidance recommends that primary care health practitioners should deliver brief interventions to their patients to change behaviours to reduce overweight and obesity. This cross-sectional study investigates UK general practitioners' (GPs) and practice nurses' communication about overweight with their overweight and obese patients. Forty general practitioners and 47 practice nurses in two inner-London primary care organizations completed a questionnaire about past practice and concerns. When there was no identified medical problem, 38% of GPs and 14% of practice nurses reported raising the issue on less than 50% of occasions. Practice nurses were more likely than GPs to raise the issue of weight, both when there was no medical problem and when there was a medical problem. When they did raise the issue of overweight, only 9% did so in the context of presenting possible solutions to weight loss or in discussions about health promotion. Fifty two per cent of GPs and 28% of practice nurses had concerns about raising the issue of overweight; the most common being that patients would react emotionally to the message. These results suggest that there is considerable room for improvement in the frequency with which primary care practitioners address the questions of weight in their overweight patients, especially amongst doctors. Training to increase skills and confidence in communicating about weight is recommended.     

A Brief Motivational Intervention for Treatment‐Refusing OCD Patients

Cognitive behavioral therapy involving exposure and response prevention (ERP) is the psychosocial treatment of choice for obsessive‐compulsive disorder (OCD). Despite this, ERP is not widely used by mental health practitioners, and so dissemination of ERP and other empirically supported treatment (ESTs) has become a priority. Even so, utilization of ESTs such as ERP remains below 50% even among therapists who self‐identify as having a cognitive behavioral orientation. Barriers to the acceptance of ERP include practical obstacles such as lack of training and the cost of treatment, but also patient variables such as treatment refusal. It has been estimated that approximately 25% of OCD patients refuse ERP. This paper describes a brief, 4‐session readiness intervention (RI) designed to decrease ERP refusal among patients with OCD. In this study, 12 patients with OCD who had refused ERP were randomized to RI or wait‐list (WL). 86% of participants in the RI condition and 20% of participants in WL condition agreed to begin ERP following the 4‐week period. ERP following RI, but not WL, was associated with a decrease in OCD symptoms comparable to that observed in OCD patients who did not refuse ERP. However, ERP following RI was associated with a high drop‐out rate (50%), a figure that exceeds that typically seen in OCD treatment studies. Techniques to reduce drop‐out as well as directions for future research are discussed.     

A brief motivational intervention for treatment-refusing OCD patients

Cognitive behavioral therapy involving exposure and response prevention (ERP) is the psychosocial treatment of choice for obsessive-compulsive disorder (OCD). Despite this, ERP is not widely used by mental health practitioners, and so dissemination of ERP and other empirically supported treatment (ESTs) has become a priority. Even so, utilization of ESTs such as ERP remains below 50% even among therapists who self-identify as having a cognitive behavioral orientation. Barriers to the acceptance of ERP include practical obstacles such as lack of training and the cost of treatment, but also patient variables such as treatment refusal. It has been estimated that approximately 25% of OCD patients refuse ERP. This paper describes a brief, 4-session readiness intervention (RI) designed to decrease ERP refusal among patients with OCD. In this study, 12 patients with OCD who had refused ERP were randomized to RI or wait-list (WL). 86% of participants in the RI condition and 20% of participants in WL condition agreed to begin ERP following the 4-week period. ERP following RI, but not WL, was associated with a decrease in OCD symptoms comparable to that observed in OCD patients who did not refuse ERP. However, ERP following RI was associated with a high drop-out rate (50%), a figure that exceeds that typically seen in OCD treatment studies. Techniques to reduce drop-out as well as directions for future research are discussed.     

Do the bishops have it right on health care reform?

The National Conference of Catholic Bishops has argued for significant government involvement in health care in order to assure respect for what they regard as the right to health care. Critics charge that the bishops are wrong because health care is not a right. In this article, it is argued that these critics are correct in their claim that health care is not a right. However, it is also argued that the premise that health care is not a right does not imply that the market is the most equitable and just system for providing health care. Natural law arguments in the tradition of Roman Catholic social teaching lead to the conclusion that a just and prosperous society has a moral obligation to provide health care even if there is no such right. Further, there are strong moral grounds for concluding that the bishops are correct in their claim that health care ought not to be considered a market commodity. It is argued that if health care ought not to be considered a commodity, then national health insurance is the best available alternative for fulfilling the social obligation to distribute health care resources justly and fairly at this time in American history. The bishops' case for government involvement can be made on the strength of the Catholic tradition in theological argumentation, independent of the claim that health care is a right.     

La décision médicale et la relation médecin–patient en oncologie

The announcement of the cancer diagnosis and his treatment is an important moment in the set up of the doctor–patient relationship. The law of contracts has long governed the relationship between the doctor and the patient. But the legislature clearly demonstrated its will to consider the patient as full actor of his health, leaving the regime of medical decision, the shared decision. This shared decision is based on an obligation to inform the patient on his health and knows many exceptions (minor patients or adults under guardianship, emergency). In Oncology, the medical decision is a decision coordinated between doctors in the multidisciplinary consultation meetings. This decision is considered as a guarantee of the quality of the medical care. It does not preclude the time of the doctor–patient relationship.     

HIV and the obligation to treat

The paper is an attempt to review the basis for the claim that physicians have a professional obligation to treat AIDS patients. Considered are the historical record, two professional codes of ethics, and several recent articles. The paper concludes that the arguments considered, which attempt to support the claim that physicians have an obligation to treat, fail. It is suggested, rather, that common humanity, which physicians share with those who suffer from AIDS, ought to be the basis for engaging in the care of AIDS patients.     

Autonomy and the refusal of life-prolonging therapy

Conclusion Autonomous decision-making over therapy options is not reducible to the refusal of unwanted medical intervention. This is a myth that has been imported from questionable assumptions in political economy, and is of little benefit to medical practice and the sometimes agonizing decisions which have to be taken by patients and their relatives. An individual's right to therapy abatement can be protected from abuse only in the context of a full understanding of autonomous choice; not merely the right to refuse, but the opportunity to receive assistance and consider alternatives. Limits are also required on the role of the surrogate in the refusal of therapy. Policies endorsing therapy abatement and exercise of the right to forego life-sustaining therapy should carry cast iron guarantees that they will not be disadvantageous to the poor and undereducated members of society. It should also be noted that fears of unlimited life-prolongation have been greatly exaggerated. In an atmosphere of governmental indifference to the plight of the sick, with the notion of welfare tuned to market forces, there is a danger that self-determination can have a restricted meaning; the option of death in the context of an underfunded health service. This may not be the time to campaign for the right to refuse therapy, but rather the time to campaign for improvements to existing therapy.     

“拔牙要签同意书案”的知情同意探究

让患者知情同意义务是近些年来在医疗诉讼过程中逐步从一般注意义务中分化出来的特殊注意义务。但如何确定患者知情同意,如何界定医生行使告知义务时的信息披露程度,一直没有一个确定的标准,在法律、医患沟通、医疗保险制度等方面还有许多要完善的地方。     

Protecting reasonable conscientious refusals in health care

Theoretical Medicine and Bioethics - Recently, debate over whether health care providers should have a protected right to conscientiously refuse to offer legal health care services—such as...     

Catholic social justice and health care entitlement packages.

This paper explores the implications of Roman Catholic teachings on social justice and rights to health care. It argues that contemporary societies, such as those in North America and Western Europe, have an obligation to provide health care to their citizens as a matter of right. Moral considerations provide a basis for evaluating concerns about the role of equality when determining health care entitlements and giving some precision to the widespread belief that the right to health care requires equal entitlement to health care benefits.     

Of community,organs and obligations: Routine salvage with a twist

This paper makes the assumption that organ transplantation is, under some conditions at least, a proper use of communal medical resources. Proceeding from this assumption, the author: (1) sketches the history of the problem; (2) briefly examines the prevalent models of communal structure and offers an alternate version; (3) discusses notions of justice and obligation derived from these different models; (4) applies these to the practice of harvesting organs for transplantation; and then (5) offers a different process for harvesting organs from the newly dead. If community is viewed as united by a set of shred goals and common values among which the value of community itself is important, then certain reciprocal obligations among members obtain. I suggest that routine salvage of organs from the newly dead be instituted but that it be routine salvage “with a twist”: rather early in life all members of the community are given the opportunity to refuse but their refusal carries the reciprocal condition that they cannot later become the recipients of that which they refuse to others.     

When pestilence prevails...physician responsibilities in epidemics

The threat of bioterrorism, the emergence of the SARS epidemic, and a recent focus on professionalism among physicians, present a timely opportunity for a review of, and renewed commitment to, physician obligations to care for patients during epidemics. The professional obligation to care for contagious patients is part of a larger "duty to treat," which historically became accepted when 1) a risk of nosocomial infection was perceived, 2) an organized professional body existed to promote the duty, and 3) the public came to rely on the duty. Physicians' responses to epidemics from the Hippocratic era to the present suggests an evolving acceptance of the professional duty to treat contagious patients, reaching a long-held peak between 1847 and the 1950's. There has been some professional retrenchment against this duty to treat in the last 40 years but, we argue, conditions favoring acceptance of the duty are met today. A renewed embrace of physicians' duty to treat patients during epidemics, despite conditions of personal risk, might strengthen medicine's relationship with society, improve society's capacity to prepare for threats such as bioterrorism and new epidemics, and contribute to the development of a more robust and meaningful medical professionalism.     

从医疗活动的特点谈医患法律关系

医疗活动具有独特的特点,这就决定了医患双方会形成独特的法律关系.在诊疗康复关系和强制性的预防保健关系中,医患双方不能以合同关系论处,而在自愿性预防保健关系和特殊服务关系中,双方却只能用合同来调整.     

Mandating vaccination: what counts as a "mandate" in public health and when should they be used?

Recent arguments over whether certain public health interventions should be mandatory raise questions about what counts as a "mandate." A mandate is not the same as a mere recommendation or the standard of practice. At minimum, a mandate should require an active opt-out and there should be some penalty for refusing to abide by it. Over-loose use of the term "mandate" and the easing of opt-out provisions could eventually pose a risk to the gains that truly mandatory public health interventions, such as childhood vaccines, have provided over the last 50 years. Already, confusion about what counts as a mandate, and about what criteria should be used to determine when a public health intervention should be implemented as a mandate, has led to some inappropriate public policy decisions. For instance, by any reasonable criteria, the yearly influenza vaccine should be mandatory for health care workers. To enforce this mandate, those who refuse vaccination should be required to sign a waiver, and patients - especially those at high risk from flu - should be informed when they receive care from unvaccinated practitioners.     

Training needs among nonmental health professionals working with service members: A qualitative investigation

Though many service members will not directly seek mental health care due to stigma and other factors, they may interact with the healthcare system in other ways including contact with first responders, nurses, and allied health care professionals. However, little attention has been spent in this regard on the educational needs of these professionals whose contact with service members and Veterans may provide the opportunity to assist Veterans in need with overcoming barriers to accessing mental health care. This qualitative study investigates the educational training needs of first responders and health care professionals in contact with military families and trauma survivors to determine whether, and what type, of additional training is needed. A sample of 42 first responders and health care professionals including emergency medical technicians, police officers, fire fighters, speech language pathologists, occupational therapists, physical therapists, and nurses were recruited to participate in 1 of 6 focus groups. Sessions were audiotaped and transcribed verbatim. Data analysis was guided by a thematic analysis approach. Thematic analyses suggest there is a significant knowledge gap with unmet educational needs of these professionals such as information on the invisible wounds of war, military culture, and screening and referring patients who present symptoms falling outside professionals’ scope of practice. Findings point to a need and desire for more robust education for first responders and health care providers around mental health concerns of military populations, including topics such as trauma, military culture, and screening tools. Efforts to develop curricula addressing these concerns are warranted.