Pathways to Medical Utilization

The role of psychologists in medical settings is evolving to include the development, delivery, and evaluation of psychosocial treatments for individuals who use disproportionate amounts of medical services. The primary purpose of this article is to present a model of psychological factors that drive health care utilization. A stepped care model of treatment delivery is also discussed along with a brief literature review depicting the impact of treatment approaches on high utilizing populations. This article concludes with recommendations for psychologists interested in providing treatment to medical utilizers.     

Ethical and legal aspects in teaching students of medicine

Due to the rapid advances in medical technology, medical students are now being faced with increasingly complex and unparalleled ethical and practical dilemmas during their training. The new and future challenges of high-tech medicine demand improvements in current medical education, not only by meeting the needs of students through humanized training programs, but also by involving them in finding solutions to the ethical and legal quandaries they encounter. Today’s students of medical universities must acquire knowledge and understanding of the ethical and legal issues relevant to the practice of medicine, and we have to do everything possible to introduce these students to the current discussions on more or less controversial ethical and legal topics. Although final answers may not be found, the very discussion, argumentation, and awakening of students’ interest should become an essential part of the core curriculum of every doctor. An earlier version of this paper was presented at an international conference, “The Ethics of Intellectual Property Rights and Patents,” held in Warsaw, Poland on 23–24 April, 2004. The author is a student and member of the Senate Committee on Teaching.     

The ethics activities of the World Medical Association

Since its formation in 1947, the World Medical Association (WMA) has been a leading voice in international medical ethics. The WMA’s principal ethics activity over the years has been policy development on a wide variety of issues in medical research, medical practice and health care delivery. With the establishment of a dedicated Ethics Unit in 2003, the WMA’s ethics activities have intensified in the areas of liaison, outreach and product development. Initial priorities for the Ethics Unit have been the review of paragraph 30 of the Declaration of Helsinki, the expansion of the Ethics Unit section of the WMA website and the development of an ethics manual for medical students everywhere. An earlier version of this paper was presented at an international conference, “The Ethics of Intellectual Property Rights and Patents,” held in Warsaw, Poland on 23–24 April, 2004.     

Parental refusals of medical treatment: the harm principle as threshold for state intervention

Minors are generally considered incompetent to provide legally binding decisions regarding their health care, and parents or guardians are empowered to make those decisions on their behalf. Parental authority is not absolute, however, and when a parent acts contrary to the best interests of a child, the state may intervene. The best interests standard is the threshold most frequently employed in challenging a parent's refusal to provide consent for a child's medical care. In this paper, I will argue that the best interest standard provides insufficient guidance for decision-making regarding children and does not reflect the actual standard used by medical providers and courts. Rather, I will suggest that the Harm Principle provides a more appropriate threshold for state intervention than the Best Interest standard. Finally, I will suggest a series of criteria that can be used in deciding whether the state should intervene in a parent's decision to refuse medical care on behalf of a child.     

TPS: A hybrid automatic-interactive system for developing proofs

The theorem proving system Tps provides support for constructing proofs using a mix of automation and user interaction, and for manipulating and inspecting proofs. Its library facilities allow the user to store and organize work. Mathematical theorems can be expressed very naturally in Tps using higher-order logic. A number of proof representations are available in Tps, so proofs can be inspected from various perspectives.     

Defining and Delineating a Duty to Prognosticate

Prognostication, the process offormulating and communicating a prognosis, isno longer considered by most physicians to bean essential task in caring for patients withserious illness. Because of this fact, it isnot surprising to find that when physiciansattempt to engage in prognostication, they doit poorly. What may be surprising to thoseoutside the medical community is the extent towhich professional norms have developed whichactively discourage physicians from engaging inprognostication. This article explores thecauses of this state of affairs and thejustifications offered for it. The conclusionis reached that physicians have a professionalresponsibility to competently engage inprognostication based upon the doctrine ofinformed consent, and that a failure or refusalto do so has not only potential legalramifications, but serious negativeimplications for many of the core issues inbioethics, such as the use of advancedirectives, palliative medicine, and medicalfutility.     

The Ethics of Alpha: Reflections on Statistics,Evidence and Values in Medicine

As health care embraces the tenets of evidence-based medicine it is important to ask questions about how evidence is produced and interpreted. This essay explores normative dimensions of evidence production, particularly around issues of setting the tolerable level of uncertainty of results. Four specific aspects are explored: what health care providers know about statistics, why alpha levels have been set at 0.05, the role of randomization in the generation of sufficient grounds of belief, and the role of observational studies. The essay concludes with recommendations to acknowledge the value permeation of outcome measures and suggests that attention to reasoning and argument analysis can augment traditional evidence-based approaches in providing a robust critical approach to medical knowledge. This revised version was published online in August 2006 with corrections to the Cover Date.     

Editorial independence at medical journals owned by professional associations: A survey of editors

The purpose of this study was to assess the degree of editorial independence at a sample of medical journals and the relationship between the journals and their owners. We surveyed the editors of 33 medical journals owned by not-for-profit organizations (“associations”), including 10 journals represented on the International Committee of Medical Journal Editors (nine of which are general medical journals) and a random sample of 23 specialist journals with high impact factors that are indexed by the Institute for Scientific Information. The main outcome measures were the authority to hire, fire, and oversee the work of the editor; the editor’s tenure and financial compensation; control of the journal’s budget; publication of material about the association; and the editor’s perceptions about editorial independence and pressure over editorial content. Of the 33 editors, 23 (70%) reported having complete editorial freedom, and the remainder reported a high level of freedom (a score of ≥8, where 10 equals complete editorial freedom and 1 equals no editorial freedom). Nevertheless, a substantial minority of editors reported having received at least some pressure in recent years over editorial content from the association’s leadership (42%), senior staff (30%), or rank-and-file members (39%). The association’s board of directors has the authority to hire (48%) or fire (55%) the editor for about half of the journals, and the editor reports to the board for 10 journals (30%). Twenty-three editors (70%) are appointed for a specific term (median term =5 years). Three-fifths of the journals have no control over their profit, and the majority of journals use the association’s legal counsel and/or media relations staff. Stronger safeguards are needed to give editors protection against pressure over editorial content, including written guarantees of editorial freedom and governance structures that support those guarantees. Strong safeguards are also needed because editors may have less freedom than they believe (especially if they have not yet tested their freedom in an area of controversy).     

Signification and Pain: A Semiotic Reading of Fibromyalgia

Patients with persistent pain who lack adetectable underlying disease challenge thetheories supporting much of biomedicalbody-mind discourse. In this context,diagnostic labeling is as inherently vulnerableto the same pitfalls of uncertainty that besetany other interpretative endeavour. The endpoint is often no more than a name ratherthan the discovered essence of a pre-existentmedical condition. In 1990 a Committee of theAmerican College of Rheumatology (ACR)formulated the construct of Fibromyalgia in anattempt to rectify a situation of diagnosticconfusion faced by patients presenting withwidespread pain. It was proposed thatFibromyalgia existed as a ``specific entity',separable from but curiously able to co-existwith any other painful condition. Epistemological and semiotic analyses ofFibromyalgia have failed to find any sign,clinical or linguistic, which coulddifferentiate it from other diffusemusculoskeletal pain states. The construct ofFibromyalgia sought to define a discernablereality outside the play of language and topass it off as a natural phenomenon. However,because it has failed both clinically andsemiotically, the construct also fails the testof medical utility for the subject inpersistent pain.     

Ethical implications in the allocation of scarce medical resources in Poland

The health care system in Poland is undergoing major change and it is possible that these changes could affect clinical research. Therefore, the situation of funding of health care is important for the future of medical research in this country. Some questions relevant in this field will be addressed. Since funds for health care and scientific research remain inadequate, their allocation raises moral, economic, legal and organisational dilemmas. The clinical aspects of resource allocation also include physicians’ responsibilities towards their patients. Scientific research, clinical medicine, and clinical research have a common denominator: they rely on trust. The physician should be a fiduciary of the patient as well as being a researcher for the benefit of the patient and for society. Some physicians and researchers, despite unethical conduct, escape disclosure and punishment, but decision-makers who wrongly allocate funds for health care and research are never held accountable for their actions. An earlier version of this paper was presented at a symposium, Scientific Misconduct: An International Perspective, organised by The Medical University of Warsaw, 16 November, 1998.