Damage Compounded: Disparities,Distrust, and Disparate Impact in End-of-Life Conflict Resolution Policies

For a little more than a decade, professional organizations and healthcare institutions have attempted to develop guidelines and policies to deal with seemingly intractable conflicts that arise between clinicians and patients (or their proxies) over appropriate use of aggressive life-sustaining therapies in the face of low expectations of medical benefit. This article suggests that, although such efforts at conflict resolution are commendable on many levels, inadequate attention has been given to their potential negative effects upon particular groups of patients/proxies. Based on the well-documented tendency among many African Americans to prefer more aggressive end-of-life medical interventions, it is proposed that the use of institutional policy to break decision making impasse in cases for which aggressive treatment is deemed “medically inappropriate” will fall disproportionately on that group. Finally, it is suggested that the development and application of institutional conflict-resolution policies should be evaluated in the context of historical and current experiences of marginalization and disempowerment, lest such policies exacerbate that experience.     

Prospective payment: its impact on psychology's role in health care

This article describes the new Medicare payment system based on diagnosis-related groups (DRGs) and its impact on professional psychology. DRGs represent medically oriented notions about how many inpatient days a prudent physician needs to effectively treat a patient who suffers from a specified disease. However, for the most part, DRGs ignore the behavioral variables that moderate entry into the tertiary care system and the subsequent use of hospital resources. Under DRGs, the development and use of behavioral treatments for somatic disorders could be discouraged. For example, many newer behavioral medicine techniques may be more time-consuming and/or expensive than traditional treatment options (e.g., bed rest vs. biofeedback for low back pain) and thus not fall within the time period or "trim points" alloted for such disorder, regardless of comparative effectiveness. Also, under the new system, psychologists can no longer bill separately for their inpatient services. It is argued that the framers of health care policies should recognize and support health psychologists in light of the fact that many of their techniques can reduce the cost and consumption of health care through programs that: reduce behavioral risk factors, increase compliance with medical regimens, and prepare patients psychologically for stressful medical procedures.     

Can applied ethics be effective in health care and should it strive to be?

Drawing upon his work in medical centers, Caplan explores the question of how well ethicists function in hospitals. He asks if their use of the "engineering model" of applied ethics, which emphasizes conceptual clarification, mastery of ethical theory, and impartiality, has made any difference in the way medicine is practiced. Noting that ethicists have been more effective in influencing heatlh policy at the national than at the institutional level, Caplan concludes that they have been less successful in teaching medical ethics, working with health personnel, and helping to formulate hospital policies. He attributes their difficulties primarily to the inadequacies of the engineering model of applied ethics for solving problems in a clinical setting. Caplan cautions ethicists to be aware both of the limitations of the engineering model and of the motives of health personnel in asking for help which may have little to do with resolving moral dilemmas.     

Affirming the Existential within Medicine: Medical Humanities, Governance, and Imaginative Understanding

This paper first distinguishes governance (collective, autonomous self-regulatory processes) from government (externally-imposed mandatory regulation); it proposes that the second of these is essentially incompatible with a conception of the medical humanities that involves imagination and vision on the part of medical practitioners. It next develops that conception of the medical humanities, as having three distinguishable aspects (all of them distinct from the separate phenomena popularly known as "arts-in-health"): first, an intellectual enquiry into the nature of clinical medicine; second, an important dimension of medical education; third, a resource for moral and aesthetic influences upon clinical practice, supporting "humane health care" as the moral inspirations behind organised medicine. Medical humanities sustains these three aspects through paying proper attention to the existential and subjective aspects of medicine. By encouraging authentic imagination among health care practitioners, medical humanities aligns well with both humane health care and governance in the sense of self-regulation. However, it can neither be achieved mechanistically nor well-measured through proxies such as patient satisfaction. Above all, it should not be allowed to supply, through inappropriate qualitative "targets," new forms of management tyranny.     

Young adults' media use and attitudes toward interpersonal and institutional forms of aggression

Links between media violence exposure and favorable attitudes toward interpersonal violence are well established, but few studies have examined whether associations extend to include favorable attitudes toward institutional forms of aggression. Studies on this topic have not assessed multiple forms of media use and statistically controlled for individual characteristics likely to influence attitudes beyond sociodemographic information. In this study, undergraduate students (N=319) aged 18-20 years (56% male) completed a survey assessing media use (number of hours per week spent playing videogames, watching movies/TV shows, watching TV sports) and attitudes toward interpersonal violence, punitive criminal justice policies, and different types of military activities (preparedness/defense and aggressive intervention). Greater number of hours spent watching TV contact sports was associated with more favorable attitudes toward military preparedness/defense, aggressive military intervention, and punitive criminal justice policies among men independently of parental education, lifetime violence exposure within the home and community, aggressive personality, and constrained problem solving style. Greater number of hours spent watching violent movies/TV was associated with more favorable attitudes toward military preparedness/defense among men and with more favorable attitudes toward interpersonal violence and punitive criminal justice policies among women, but these associations became non-significant when adjusting for covariates.     

The next exclusion debate: assessing technology, ethics, and intellectual disability after the Human Genome Project

Recent scientific discoveries have made it much easier to test prenatally for various genetic disabilities, such as Down syndrome. However, while many observers have heralded such "advances" for their effectiveness in detecting certain conditions, others have argued that they perpetuate discrimination by preventing the birth of children with disabilities. This article examines the ethical and social implications of the Human Genome Project for individuals with intellectual disabilities and their families. It details the critique of prenatal testing articulated by many disability rights activists as well as scholarly and professional responses to that critique. A review of the pertinent research literature includes perspectives of genetic professionals, ethicists, disability studies scholars, parents of children with disabilities, and disabled individuals themselves. Finally, the article explores how future research endeavors, policies, and practices may more effectively integrate and respect the positions of these various stakeholders.     

Ethics Consultant: Problem Solver or Spiritual Counselor?

The primary goal of ethics consultation should be to provide effective assistance to patients and families in obtaining care that is duly responsive to their rights and their needs. The consultation reported by Mark Bliton fails in this regard because it never ascertains why the consultation was called; makes little attempt to ascertain the motives of those involved; avoids exploration of the ethical concerns of family, attending or staff; makes no connection with institutional policies or practices; uncritically adopts and serves the medical treatment ethos; and substitutes fellowfeeling for compassionate action.     

Legal procedures in Wanglie: a two-step, not a sidestep

Hospital policies...have a very limited role in addressing the substantive issue of authority with regard to nonbeneficial therapies. First, they could not be limited, as Mishkin suggests, to persons in a persistent vegetative state. Nonbeneficial therapies encompass many other scenarios including ineffective cancer chemotherapy or open-heart surgery on profoundly demented persons. Second, I am not convinced that families or patients could be meaningfully informed of the specific relevance of such policies to their care in advance of a dispute. Most importantly, the view that such policies are required as a foundation to withhold nonbeneficial therapy implies that patients otherwise have a new right to command the provision of nonbeneficial therapies....It may well be judicially preferable to ask directly for declarative relief from a duty to provide a treatment, as Mishkin suggests. I am not convinced that such an approach would be "ethically" superior....Third, the novel, declarative approach directly risks a precedent that would affirm the family's right to demand futile therapy....Ultimately, when public policy on this kind of dispute is clearer, a declarative strategy may well be preferable. For now, the Wanglie case has outlined the fundamental issues of this novel legal question and has generated a fruitful discussion of a complex issue in patient care and public policy.     

Toward a Positive Perspective on Violence Prevention in Schools: Building Connections

As concerns about the level of school violence have increased in recent years, many schools have instituted policies designed to deter or prohibit violent and aggressive acts on school campuses. Although well intentioned, most such policies tend to be reactive and punitive in nature. In contrast, this article proposes a positive approach to violence prevention based on establishing meaningful connections between students, their families, peers, and school.     

Behavioral equipoise: a way to resolve ethical stalemates in clinical research

Randomized trials depend on clinicians feeling that they are morally justified in allowing their patients to be randomized across treatment arms. Typically such justification rides on what has been called "clinical equipoise"--when there is disagreement of opinion among the community of experts about whether one treatment is better than another, then physicians can ethically enter their patients into a clinical trial, even if individual physicians are not at equipoise. Recent debates over prominent studies, however, illustrate that controversy can be easily created rather than dispelled by trials, with many clinicians choosing not to use the proven therapy until they receive more convincing evidence of its superiority. In such situations, we propose that a new standard of equipoise be used to guide decisions about the ethical justifications for research trials--a standard of behavioral equipoise. Under behavioral equipoise, a trial is potentially justifiable if it addresses behavioral resistance to prior scientific evidence.     

Using Articulated Thoughts in Simulated Situations to Assess Cognitive Activity in Aggressive and Nonaggressive Adolescents

Articulated Thoughts in Simulated Situations (ATSS) is a think aloud method for examining a person's thought content as it unfolds in the situation. We used the ATSS to investigate the cognitive activity of aggressive and nonaggressive male and female adolescents as they listened to an audiotaped depiction of an ambiguous but provocative interaction with another student. Eighty-one adolescents participated in a 2 × 2 factorial experiment. The two factors were gender and aggressive vs. nonaggressive background. Students in the aggressive group had a history of aggressive behavior in the past year that was severe enough to warrant their arrest or suspension from school. Students in the nonaggressive group had no such history. As a secondary measure of anger and aggressiveness, we administered the State-Trait Anger Expression Inventory-2 (STAXI-2). As predicted, males, compared to females, expressed more aggressive intent on the ATSS. Likewise, aggressive, compared to nonaggressive, adolescents expressed more anger and aggressive intent on the ATSS, as well as more intense feelings of anger, less control over their anger, and a greater tendency to externalize angry feelings on the STAXI-2. As expected, scores on the ATSS were related to scores on the STAXI-2. We concluded that the ATSS is a useful method for assessing cognitive activity that may mediate aggressive behavior in adolescents.     

Autonomy,constraining options,and organ sales

Although there continues to be a chronic shortage of transplant organs the suggestion that we should try to alleviate it through allowing a current market in them continues to be morally condemned, usually on the grounds that such a market would undermine the autonomy of those who would participate in it as vendors. Against this objection Gerald Dworkin has argued that such markets would enhance the autonomy of the vendors through providing them with more options, thus enabling them to exercise a greater degree of control over their bodies. Paul Hughes and T. L. Zutlevics have recently criticized Dworkin's argument, arguing that the option to sell an organ is unusual in that it is an autonomy–undermining "constraining option" whose presence in a person's choice set is likely to undermine her autonomy rather than enhance it. I argue that although Hughes' and Zutlevics' arguments are both innovative and persuasive they are seriously flawed — and that allowing a market in human organs is more likely to enhance vendor autonomy than diminish it. Thus, given that autonomy is the preeminent value in contemporary medical ethics this provides a strong prima facie case for recognizing the moral legitimacy of such markets.     

Unsanctioned aggression in rugby union: relationships among aggressiveness,anger, athletic identity,and professionalization

Aggressive players who intentionally cause injury to their opponents are common in many sports, particularly collision sports such as Rugby Union. Although some acts of aggression fall within the rules (sanctioned), others do not (unsanctioned), with the latter tending to be less acceptable than the former. This study attempts to identify characteristics of players who are more likely to employ unsanctioned methods in order to injure an opponent. Male Rugby Union players completed questionnaires assessing aggressiveness, anger, past aggression, professionalization, and athletic identity. Players were assigned to one of two groups based on self‐reported past unsanctioned aggression. Results indicated that demographic variables (e.g., age, playing position, or level of play) were not predictive of group membership. Measures of aggressiveness and professionalization were significant predictors; high scores on both indicated a greater probability of reporting the use of unsanctioned aggressive force for the sole purpose of causing injury or pain. In addition, players who had been taught how to execute aggressive illegal plays without detection were also more likely to report using excessive force to injure an opponent. Results provide further support that highly professionalized players may be more likely to use methods outside the constitutive rules of Rugby Union in order to intentionally injure their opponents. Results are discussed within the context of the increasing win‐at‐all‐cost attitude that is becoming more prevalent in sport and its implications for youth athletes. Aggr. Behav. 35:237–243, 2009. © 2009 Wiley‐Liss, Inc.     

Relating ethnic identity, acculturation, and attitudes toward treating minority clients

This study assessed the relationship among the ethnic identity, acculturation, and self-concepts of minority health care professionals and their attitudes toward treating minority clients and using alternative therapies. The sample consisted of 150 medical students of Indian descent. Strong ethnic identity and acculturation related to high self-esteem, self-clarity, the likelihood of treating more minority patients, and the use of alternative therapies. The more "Westernized" participants expressed less of a preference for serving minority patients and believed themselves to be less effective in serving minorities. Gender differences in some aspects of ethnic identity and attitudes were found. The results imply that a focus on acculturation and ethnicity in all client-clinician psychological research is critical, and especially in cases of cultural matching.     

Oversight of research involving the dead

Research involving the dead, especially heart-beating cadavers, may facilitate the testing of potentially revolutionary and life-saving medical treatments. However, to ensure that such research is conducted ethically, it is essential to: (1) identify appropriate standards for this research and (2) assign institutional responsibility and a mechanism for oversight. Protocols for research involving the dead should be reviewed by a special committee and assessed according to nine standards intended to ensure scientific merit, to protect deceased patients and their families, and to promote institutional integrity and responsibility. Federal regulation of research involving the dead will foster appropriate standards and, equally importantly, help establish the acceptability of such research.     

The use of animals in medical education and research

After noting why the issue of the use of animals in medical education and research needs to be addressed, this article briefly reviews the historical positions on the role of animals in society and describes in more detail the current positions in the wide spectrum of positions regarding the role of animals in society. The spectrum ranges from the extremes of the animal exploitation position to the animal liberation position with several more moderate positions in between these two extremes. Then the philosophical issue of the moral agency of animals is discussed in terms of an explication of the concept of rights and the concept of personhood. Further research is suggested concerning institutional policies regarding medical students who refuse to do physiology dog labs or other assignments which involve the suffering and/or death of animals.     

Chronic illness and aggressive behaviour: A population-based study of 4-year-olds

The objective of this study was to examine the hypothesis that aggressive behaviour is explained by various medical conditions. The current study investigated this hypothesis in a population-based study of families with a 4-year-old child (n?=?1915). Maternal reports of child health and development were assessed and a paediatrician examined a subsample (n?=?263) with a chronic illness. Twice as many toddlers with a chronic physical disorder displayed aggressive behaviour when compared with toddlers without such disorders. All seven medical diagnostic categories included children with aggressive behaviour, but the highly prevalent condition of asthma contributed to more than a third of the cases with co-occurrence of chronic illness and aggressive behaviour. Neurological, sensory and skin/joint disorders accounted for another third. Subsequent analyses showed that poor language was an additional risk factor while attending day-care centres in groups with 5?–?15 children was a protective factor against aggressive behaviour.     

Irradiated by Distress: Observing Psychic Pain in Health-Care Organizations

The authors describe the history and underlying ideas of a project to observe health-care organizations. Staff in medical and psychiatric institutions are faced with major anxieties in their work with ill people and these may be dealt with in various more or less defensive ways. It is argued that institutional observation can be a tool to detect and understand the dynamics, defensive techniques and culture of a health-care organization, and that for those working in such institutions it can be a useful learning instrument. Two observations, of a mental health hostel and a medical ward, are described in some detail.