Social ethics,the philosophy of medicine,and professional responsibility

The social ethics of medicine is the study and ethical analysis of social structures which impact on the provision of health care by physicians. There are many such social structures. Not all these structures are responsive to the influence of physicians as health professionals. But some social structures which impact on health care are prompted by or supported by important preconceptions of medical practice. In this article, three such elements of the philosophy of medicine are examined in terms of the negative impact on health care of the social structures to which they contribute. The responsibilities of the medical profession and of individual physicians to work to change these social structures are then examined in the light of a theory of profession.     

Ethical and Professional Challenges of Genetic Counseling – the Case of Austria

Genetic counseling is gaining in importance with the increasing application of genetic testing for diagnosis and clinical treatment. Genetic counseling often raises ethical and professional challenges and prior research has categorized them into 16 domains. The purpose of this study was to analyze the situation in Austria on the basis of these challenges and discuss it in the national and international context. While in some countries there is a special profession for genetic counseling, in Austria it is provided by medical geneticists or other physicians in the context of their specialization. Psychosocial professionals might be consulted or brought in if necessary. Results from 95 survey respondents (including physicians and psychosocial professionals) revealed a greater interest in the topic of genetic counseling by medical specialists other than medical geneticists. The most frequently encountered challenges among physicians were informed consent, organizational constraints, withholding information, and attaining/maintaining proficiency. The psychosocial professionals experienced maintaining proficiency and organizational constraints as the prevalent challenges. Additional findings and practice implications are presented.     

The physician and social renewal: Julius B. Richmond as role model

We live in an age of “high tech” medicine which affects both health care recipients and physicians who are taught its many wonders and uses. It is easy in this atmosphere of specialization for clinicians, professors and medical students to become isolated and to ignore social issues which affect health care in its broadest sense. Individuals who are committed to the “common good” are the ones historically who have been effective change agents. It would be tragic simply to stand back and allow the cynical and greedy to dominate any profession which deals with the poor, the uninsured and the homeless. It is imperative for physicians to take a broad view of today's problems in health care delivery systems, for they can have an enormous impact on the kind of world our children will inherit. It is essential for physicians to become involved in social concerns, and in improving health care delivery, at all levels in their practice. Given their power and prestige, it is crucial for physicians and aspiring physicians to have positive role models. Dr. Julius B. Richmond provides an admirable example of a physician who cares about his profession, his patients and his nation. Through his research, his public service and his teaching, Dr. Richmond has demonstrated the difference a single individual can make in improving the quality of life for all Americans.     

A History of Physician Suicide in America

Over the course of the last century, physicians have written a number of articles about suicide among their own. These articles reveal how physicians have fundamentally conceived of themselves, how they have addressed vulnerability among their own, and how their self-identification has changed over time, due, in part, to larger historical changes in the profession, psychiatry, and suicidology. The suicidal physician of the Golden Age (1900–1970), an expendable deviant, represents the antithesis of that era’s image of strength and invincibility. In contrast, the suicidal physician of the modern era (1970 onwards), a vulnerable human being deserving of support, reflects that era’s frustration with bearing these unattainable ideals and its growing emphasis on physician health and well-being. Despite this key transition, specifically the acknowledgment of physicians’ limitations, more recent articles about physician suicide indicate that Golden Age values have endured. These persistent emphases on perfection and discomfort with vulnerability have hindered a comprehensive consideration of physician suicide, despite one hundred years of dialogue in the medical literature.     

"Evidence-debased medicine" and the integrity of the medical profession

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.     

Sex differences in the professional orientation of first-year medical students

This article, presenting the findings from a 1975 survey of first-year medical students in the state of North Carolina, explores the relationship between students' sex and professional orientations considered relevant to current health care problems. The professional orientations concern four problem areas: (1) physicians' relationships with patients, (2) political and economic change in the medical profession, (3) the treatment of women physicians and women patients, and (4) geographic and specialty mal-distribution of physicians. Substantial sex differences are found for some professional orientations. As hypothesized, women orient more highly than men to humanizing physician-patient relationships, political and economic change in medicine, the problems facing women physicians and patients, and expecting an inner-city practice. Implications of the findings for health care and medical education are discussed.This report is based on the author's doctoral dissertation, Boys and Girls in White: Professional Orientation of the Student Physician Department of Sociology, Duke University, 1976. The author would like to express appreciation to Jim House for his continued guidance and encouragement as dissertation advisor.     

Towards a Confucian Virtue Bioethics: Reframing Chinese Medical Ethics in a Market Economy

This essay addresses a moral and cultural challenge facing health care in the People’s Republic of China: the need to create an understanding of medical professionalism that recognizes the new economic realities of China and that can maintain the integrity of the medical profession. It examines the rich Confucian resources for bioethics and health care policy by focusing on the Confucian tradition’s account of how virtue and human flourishing are compatible with the pursuit of profit. It offers the Confucian account of the division of labor and the financial inequalities this produces with special attention to China’s socialist project of creating the profession of barefoot doctors as egalitarian peasant physicians and why this project failed. It then further develops the Confucian acknowledgement of the unequal value of different services and products and how this conflicts with the current system of payment to physicians which has led to the corruption of medical professionalism through illegal supplementary payments. It further gives an account the oblique intentionality of Confucian moral psychology that shows how virtuous persons can pursue benevolent actions while both foreseeing profit and avoiding defining their character by greed. This account of Confucian virtue offers the basis for a medical professionalism that can function morally within a robustly profit-oriented market economy. The paper concludes with a summary of the characteristics of Confucian medical professionalism and of how it places the profit motive within its account of virtue ethics.     

The medical profession and the corporatization of the health sector

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.     

Report of the AMA Council on Ethical and Judicial Affairs: professionalism in the use of social media

Although many physicians have been using the internet for both clinical and social purposes for years, recently concerns have been raised regarding blurred boundaries of the profession as a whole. In both the news media and medical literature, physicians have noted there are unanswered questions in these areas, and that professional self-regulation is needed. This report discusses the ethical implications of physicians' nonclinical use of the internet, including the use of social networking sites, blogs, and other means to post content online. It does not address the clinical use of the internet, such as telemedicine, e-prescribing, online clinical consultations, health-related websites, use of electronic media for clinical collaboration, and e-mailing patients (some of which are already covered in the AMA's Code of Medical Ethics).     

Integrating Individual and Organizational Perspectives for Career Development and Change

This article illustrates how traditional concepts of person-environment fit and transition can be adapted to deal with change, and highlights the advantages of an integrated organizational and individual perspective on career development. Using an adapted version of the Minnesota Theory of Work Adjustment and a “Me Incorporated” metaphor, the article illustrates the need for both the individual and an organization to consider immediate and future demand and supply factors in relation to the other. In addition to placing a change overlay on training, selection and career development, the article illustrates how recommendations for dealing with organizational change can be adapted for use by “Me Incorporated”.     

The physician as moral entrepreneur

This paper argues that the work of the contemporary physician is at least in part the work of a moral entrepreneur. The effects of religious affiliation and religiosity on the decision making of a modern doctor are examined in an analysis of the responses of 231 physicians to a mailed questionnaire. Decision-making issues were considered to be those with social/moral implications. Religious physicians tend to favor clergy involvement in social and procreative issues. Roman Catholic physicians oppose the involvement of the medical profession in birth control issues.     

Trust in the medical profession and patient attachment style

Attachment style is a person’s approach to interpersonal relationships, which develops from early experiences with primary caregivers and can remain stable into adulthood. Depending on a person’s attachment style, the amount of trust one has in others can vary when forming relationships, and trust is important in formation of the patient–physician relationship. The purpose of this study was to see if there is an association between attachment style and trust in physicians in general. Participants were recruited from an emergency department (ED) and an online university participant pool, and completed short questionnaires assessing attachment style and trust in the medical profession. Results revealed that individuals with a fearful attachment style reported significantly lower levels of trust in the medical profession than those with a secure attachment style. ED participants also reported higher levels of trust in the medical profession in comparison to student participants. This study provides a better understanding of trust in the medical profession, and insight into future care for patients who have low trust.     

Toward an understanding of the relationships among organizational change, individual differences, and changes in person-environment fit: a cross-level study

Organizational behavior literature has not typically viewed person-environment (P-E) fit as an outcome of change. Whereas the study of antecedents to employees' fit with their work environment has largely been restricted to the selection and socialization of newcomers, this study examines individuals' perceptions of changes in P-E fit in relation to organizational changes occurring in 34 different organizational work units. Results suggest that the relationships between organizational change and perceived changes in fit are best understood as interactions between the characteristics of the change process, the extent of change, and individual differences. Both age and mastery orientation related to perceived changes in P-E fit through interactions with aspects of the change process.     

Trust in managed care organizations

Two basic criticisms of managed care are that it erodes patient trust in physicians and subjects physicians to incentives and pressures that compromise the physician's fiduciary obligation to the patient. In this article, I first distinguish between status trust and merit trust, and then argue (1) that the value of status trust in physicians is probably over-rated and certainly underdocumented; (2) that erosion of status trust may not be detrimental if accompanied by an increase in well-founded merit trust; and (3) that under conditions of managed care the physician's commitment to traditional medical ethics cannot serve as an adequate basis for merit trust. Next, drawing on an analogy between managed care organzations and politics, I argue that (4) the most appropriate basis for merit trust in managed care is a conception of organizational legitimacy that includes procedural justice, empowerment of constructive criticism within the organization, and organizational accommodation of the noninstrumental commitment to patient well-being that is distinctive of medical professionalism. I then explore the conditions necessary for robust competition for merit trust among managed care organizations and indicate the kinds of public policies needed to facilitate such competition. Finally, I show how the account of organization-based merit trust can accommodate the special fiduciary obligation of medical professionals, without indulging in the delusion that it is the physician's fiduciary obligation always to provide all care that is expected to be of any net benefit to the patient.     

Professional Autonomy and the Normative Structure of Medical Practice

Professional autonomy is often described as a claim of professionalsthat has to serve primarily their own interests. However, it can also beseen as an element of a professional ideal that can function as astandard for professional, i.e. medical practice. This normativeunderstanding of the medical profession and professional autonomy facesthree threats today. 1) Internal erosion of professional autonomy due toa lack of internal quality control by the medical profession; 2)the increasing upward pressure on health care expenses that calls for ahealth care policy that could imply limitations for the professionalautonomy of physicians; 3) a distorted understanding of theprofession as being based on a formal type of knowledge and relatedtechnology, in which other normative dimensions of medical practice areneglected and which frustrates meaningful communication betweenphysicians and patients. To answer these threats a normative structureanalysis of medical practice is presented, that indicates whichprinciples and norms are constitutive for medical practice. It isconcluded that professional autonomy, normatively understood, should bemaintained to avoid the lure of the technological imperative and toprotect patients against third parties' pressure to undertreatment.However, this professional autonomy can only be maintained if members ofthe profession subject their activities and decisions to a criticalevaluation by other members of the profession and by patients and ifthey continue to critically reflect on the values that regulate today'smedicine.     

Bioethics and anti-bioethics in light of Nazi medicine: what must we remember?

Only recently have historians explored in depth the role of the medical profession in Nazi Germany. Several recent works reveal that physicians joined the Nazi party in disproportionate numbers and lent both their efforts and their authority to Nazi eugenic and racist programs. While the crimes of the physician Mengele and a few others are well known, recent research points to a much broader involvement by the profession, even in its everyday clinical work. Analogous activities existed in the German legal and industrial communities; disruption of the medical ethic thus sprang from the broader social contexts of Nazi Germany. The new United States Holocaust Memorial Museum, now opening on the Mall in Washington, D.C., will have an opportunity to educate the public about both the great crimes at Auschwitz and other camps, and the gradual but thorough degradation of ethics in the German medical profession. From this presentation, contemporary bioethics can ponder the proper use of the Nazi analogy in bioethical debate.     

组织成员地位的形成及影响机制

组织成员地位通常是指组织内个体受组织其他成员尊重和钦佩的程度,是近些年备受关注的一个心理学构念。虽然组织成员地位与权力、阶层、面子、基于组织的自尊等概念具有一定的关联性,但它们之间存在着明显的界限。组织成员地位主要受到外在显性因素(形体特征、人口统计特征)、内在心理因素(人格、认知、情绪、行为)以及神经生理因素(睾酮激素、皮质醇激素)的影响,并能够对组织成员的认知、情绪、行为和绩效产生显著的影响。未来研究应当进一步区分组织成员地位的维度,探索组织成员地位的生物学基础和文化差异,关注组织成员地位的动态演化及其后果,并检验团队和组织层面地位分布的作用机制。     

Professional Autonomy in Belgium

The Belgian health care system has a few features that may havecontributed to the rising costs of health care: patients' freechoice of physicians, large clinical freedom of physicians, essentiallya fee-for-service remuneration for medical specialists in which the feesare agreed between insurance funds and physicians. The increased medicalconsumption and costs have prompted the state and insurance companies totake measures that limit the professional autonomy of the physicians.Access to medical education, free until 1997, is now restricted. Themedical profession is organized in the Order of Physicians that hasestablished a code of professional ethics that has moral but not legalforce. So far, there is no special legislation for thepatient–physician relationship, though laws on specific issueslike organ transplantation contain duties for physicians. In recentyears a debate is taking place on patients' rights, of which informedconsent is central and gaining importance in medico-legal publications.An analysis of (ethical and legal) regulations concerning thewithholding or withdrawal of treatment by physicians demonstrate thatthe profession still enjoys a large clinical autonomy, though duediscussion with the patient has become more explicitly required. Therespect for professional autonomy is not primarily due to any formalpower that the Order of Physicians would have, but is rather grounded inthe generally high quality of the patient–physician relationshipthat in ethical terms is considered essentially as a confidencerelationship rather than a contractual relationship.     

Voluntary Control of Behavior and Responsibility

Malpractice insurance rates have created a crisis in American medicine. Rates are rising and reimbursements are not keeping pace. In response, physicians in the states hardest hit by this crisis are feeling compelled to take political action, and the current action of choice seems to be physician strikes. While the malpractice insurance crisis is acknowledged to be severe, does it justify the extreme action of a physician walkout? Should physicians engage in this type of collective action, and what are the costs to patients and the profession when such action is taken? I will offer three related arguments against physician strikes that constitute a prima facie prohibition against such action: first, strikes are intended to cause harm to patients; second, strikes are an affront to the physician-patient relationship; and, third, strikes risk decreasing the public's respect for the medical profession. As with any prima facie obligation, there are justifying conditions that may override the moral prohibition, but I will argue that the current malpractice crisis does not rise to the level of such a justifying condition. While the malpractice crisis demands and justifies a political response on the part of the nation's physicians, strikes and slow-downs are not an ethically justified means to the legitimate end of controlling insurance costs.