The use of the placebo effect in clinical medicine — ethical blunder or ethical imperative?

The current debate in medical ethics on placebos focuses mainly on their use in health research. Whereas this is certainly an important topic the discussion tends to overlook another longstanding but nevertheless highly relevant question, namely if and how the placebo effect should be employed in clinical practice. This paper describes the way the placebo effect is perceived in modern medicine and offers some historical reflections on how these perceptions have developed; discusses elements of a definition of the placebo effect; and suggests some conditions under which making use of the therapeutic potential of the placebo effect can be ethically acceptable, if not warranted. An earlier version of this paper was presented at an international conference, “Placebo: Its Action and Place in Health Research Today,” held in Warsaw, Poland on 12–13 April, 2003. Nikola Biller-Andorno, MD, PhD, is Assistant Professor in the Dept. of Medical Ethics and History of Medicine, University of Goettingen, Germany. Dr. Biller-Andorno also serves as an ethicist for the World Health Organization (WHO). This paper does not necessarily reflect the views of the World Health Organization.     

On the possibility and desirability of constructing a neutral conception of disability

Disagreement about the properattitude toward disability proliferates. Yetlittle attention has been paid to an importantmeta-question, namely, whether ``disability' isan essentially contested concept. If so, recentdebates between bioethicists and the disabilitymovement leadership cannot be resolved. Inthis essay I identify some of the presumptionsthat make their encounters so contentious. Much more must happen, I argue, for anydiscussions about disability policy andpolitics to be productive. Progress depends onconstructing a neutral conception ofdisability, one that neither devaluesdisability nor implies that persons withdisabilities are inadequate. So, first, I clearaway the conceptual underbrush that makes usthink our idea of disability must bevalue-laden. Second, I sketch someconstituents of, and constraints upon, aneutral notion of disability. This revised version was published online in June 2006 with corrections to the Cover Date.     

论当前医疗纠纷的表现特点,处理及防范对策

报道本教研室４３年３１６例医疗纠纷尸检资料的分析结果,结合实际工作经验与体会,论述当前医疗纠绿的表现特点,处理对策和防范措施。认为近年来医疗纠纷逐渐增多;发生科室以妇产科和外科多见;医疗纠纷中非医疗事故多于医疗事故。处理对策建议是：遵循法律,注意程序,讲究方法,公平合理。指出完善医疗管理是防范医疗纠纷的关键,提高医疗水平是防范医疗纠纷的根本。     

Employment Characteristics and Salaries of Psychologists in United States Medical Schools: Past and Current Trends

In 1997 the Research Office of the American Psychological Association (APA) collaborated with the Association of Medical School Psychologists (AMSP) to conduct a comprehensive employment and salary survey of psychologists employed in medical schools and academic health centers. Questionnaires were mailed to 3894 psychologists; postcard reminders and a follow-up mailing to nonresponders resulted in a final 50% response rate. The questionnaire addressed appointment characteristics, department and school characteristics, employment activities, salary information, demographics, and changes in the medical school work environment that have occurred as a result of managed care. This survey, the 1997 Employment Characteristics and Salaries of Medical School Psychologists, is the most comprehensive analysis to date of the practice of psychology in U.S. schools of medicine and academic health centers. This article reports the most salient findings from this survey.     

The Future of Psychology in Academic Health Care Centers

A promising opportunity exists to continue psychology's move beyond its traditional mental health emphasis into a general health care discipline. Abundant empirical evidence supports that psychologists treat a wide array of physical disorders as well as psychological components of medical problems. The immediate issues confronting psychology's full emergence into the health care world are discussed and recommendations are offered to assure the success of this initiative. Office of the Senior Vice President and Provost     

Moral Perception and the Pursuit of Medical Philosophy

This paper begins by examining the claim that the practice of medicine is essentially a moral endeavor. According to this view, all clinical practice has moral content, and each clinical situation has a moral dimension. I suggest that in order to recognize this moral dimension, clinicians must engage in an interpretive process, and that they must be able to interpret clinical data in ethical terms. However, clinicians often lack the ‘moral perception’ required to appreciate this moral dimension. I will argue that physicians lack moral perception when the clinical data they are given do not offer sufficient opportunity for interpretation. This paper draws on the work of Merleau-Ponty to suggest that this loss of interpretation is, paradoxically, the result of the way that patients experience illness. This thesis may be productive, first, because it suggests opportunities to explore the process of moral perception. This thesis also suggests ways for ethicists and educators to enhance clinicians' perception of the ethical dimensions of clinical practice. Finally, the concept of moral perception, when grounded in the patient's experience of illness, creates a fruitful area of inquiry that warrants inclusion in what may someday be the philosophy of medicine's canon. This revised version was published online in August 2006 with corrections to the Cover Date.     

Making Decisions About Life-Sustaining Medical Treatment in Patients With Dementia

The problem of decision-making capacity in patients with dementia, such as those with early stage Alzheimer's, can be vexing, especially when these patients refuse life-sustaining medical treatments. However, these patients should not be presumed to lack decision-making capacity. Instead, an analysis of the patient's decision-making capacity should be made. Patients who have some degree of decision-making capacity may be able to make a choice about life-sustaining medical treatment and may, in many cases, choose to forgo treatment.     

Sterilization, Catholic health care, and the legitimate autonomy of culture.

Disagreement over the legitimacy of direct sterilization continues within Catholic moral debate, with painful and at times confusing ramifications for Catholic healthcare systems. This paper argues that the medical profession should be construed as a key moral authority in this debate, on two grounds. First, the recent revival of neo-Aristotelianism in moral philosophy as applied to medical ethics has brought out the inherently moral dimensions of the history and current practice of medicine. Second, this recognition can be linked to Catholic morality through Vatican II's affirmation of the legitimate autonomy of culture, including the sciences. A partial precedent for understanding the moral authority of medicine can be found in the recent history of Catholic medical morality, and we further argue that a full contemporary recognition of that authority would weigh against an absolute prohibition of direct sterilizations. Institutionally, we propose the allowance of direct sterilizations in cases where the clinically perceived biomedical good of the patient is at stake.     

A Method for Introducing the Concepts of Chaos Theory to Medical Students

Chaos theory is beginning to find applications in the field of medicine. The theory of chaos should be introduced to students to help them as they make the transition from learning the scientific literature to actually applying this newly acquired knowledge in clinical situations. Chaos theory will give the students a powerful conceptual framework from which they can better understand the limits of predictability in clinical situations. Failure to understand the limits of predictability in chaotic natural systems will invariably lead to frustration in both patients and physicians.     

From principles to principals: The new direction in medical ethics

Many alternatives or supplements to principalism seek to reconnect medical ethics with the thoughts, feelings, and motivations of the persons directly involved in ethically troublesome situations. This shift of attention, from deeds to doers, from principles to principals, acknowledges the importance of the moral agents involved in the situation — particular practitioners, patients, and families. Taking into account the subjective, lived experience of moral decision-making parallels recent efforts in the teaching of medicine to give the patient's subjectivity — his or her personal experience of being sick or disabled — epistemological parity with scientific medicine's objective, biomedically-oriented view of the person's sickness or disability.Moreover, the shift from principalism to principals signals a growing realization that ethical problems in the profession of medicine are inseparable from its practice. Philosophers and other humanists working in medicine should resist the temptation to institutionalize a professional role as solver of ethical problems, clarifier of values, or mediator of disputes and work instead to help practitioners practice medicine reflectively.