Determining medical fitness to drive: physicians'' responsibilities in Canada.

Current legislation indicates that physicians in Canada have a legal responsibility to know which medical conditions may impede driving ability, to detect these conditions in their patients and to discuss with their patients the implications of these conditions. The requirements to report unfit drivers vary among the provinces, and the interpretations of the law vary among the courts; therefore, physicians' risks of liability are unclear. Physicians may be sued by their patients if they fail to counsel the patients on the dangers of driving associated with certain medications or medical conditions. Physicians may also face legal action by victims of motor vehicle accidents caused by their patients if the court decides that the physicians could have foreseen the danger of their patients' continuing to drive. Physicians' legal responsibilities to report patients with certain medical conditions override their ethical responsibilities to keep patients' medical histories confidential.     

Subtracting insult from injury: addressing cultural expectations in the disclosure of medical error

This article proposes that knowledge of cultural expectations concerning ethical responses to unintentional harm can help students and physicians better to understand patients' distress when physicians fail to disclose, apologize for, and make amends for harmful medical errors. While not universal, the Judeo-Christian traditions of confession, repentance, and forgiveness inform the cultural expectations of many individuals within secular western societies. Physicians' professional obligations concerning truth telling reflect these expectations and are inclusive of the disclosure of medical error, while physicians may express a need for self-forgiveness after making errors and should be aware that patients may also rely upon forgiveness as a means of dealing with harm. The article recommends that learning how to disclose errors, apologize to injured patients, ensure that these patients' needs are met, and confront the emotional dimensions of one's own mistakes should be part of medical education and reinforced by the conduct of senior physicians.     

Should informed consent be based on rational beliefs?

Our aim is to expand the regulative ideal governing consent. We argue that consent should not only be informed but also based on rational beliefs. We argue that holding true beliefs promotes autonomy. Information is important insofar as it helps a person to hold the relevant true beliefs. But in order to hold the relevant true beliefs, competent people must also think rationally. Insofar as information is important, rational deliberation is important. Just as physicians should aim to provide relevant information regarding the medical procedures prior to patients consenting to have those procedures, they should also assist patients to think more rationally. We distinguish between rational choice/action and rational belief. While autonomous choice need not necessarily be rational, it should be based on rational belief. The implication for the doctrine of informed consent and the practice of medicine is that, if physicians are to respect patient autonomy and help patients to choose and act more rationally, not only must they provide information, but they should care more about the theoretical rationality of their patients. They should not abandon their patients to irrationality. They should help their patients to deliberate more effectively and to care more about thinking rationally. We illustrate these arguments in the context of Jehovah's Witnesses refusing life-saving blood transfusions. Insofar as Jehovah's Witnesses should be informed of the consequences of their actions, they should also deliberate rationally about these consequences.     

Physicians and acquired immunodeficiency syndrome. What patients think about human immunodeficiency virus in medical practice

Are patients concerned about going to a physician who is infected with human immunodeficiency virus (HIV) or one who is treating HIV-infected patients? To answer these questions, we surveyed a nationwide sample of 2000 interviews (response rate, 75%). Forty-five percent of all respondents believed that physicians who were HIV infected should not be allowed to continue to practice. More than half of those who had seen a physician in the past 5 years said they would change physicians if they knew their physician were HIV infected, while one fourth said they would seek care elsewhere if their physician were treating people with HIV disease. These data suggest that patients are concerned about HIV in their physicians' offices. The American Medical Association recommends that HIV-infected physicians continue to practice as long as there is no risk to their patients. Physicians and the public need to be educated about this policy and its appropriateness.     

Early intervention for alcohol use: family physicians' motivations and perceived barriers.

OBJECTIVE: To elucidate family physicians' motivations concerning early intervention for alcohol use and their perceived barriers to such intervention. DESIGN: Qualitative study with the use of focus groups and semistructured interviews. SETTING: Community-based, fee-for-service family-medicine practices in London, Ont. PARTICIPANTS: Twelve focus-group participants recruited through telephone contact by two family physicians on the project team. Participants were required to be physicians in family practice in London. Twelve interview participants recruited through a grand-rounds presentation at two local hospitals. Participants were required to be physicians in a community-based family practice in which primary care was not delivered by residents and to have agreed to participate in all phases (e.g., needs assessment, training and evaluation) of a training program on interventions to help patients reduce alcohol consumption or quit smoking. MAIN OUTCOME MEASURES: Motivations concerning early intervention for alcohol use and perceived barriers to such intervention, as identified by physicians. RESULTS: Physicians in the focus groups and those interviewed endorsed their role in helping patients to reduce alcohol consumption and cited several reasons for the importance of that role. There was strong support for viewing alcohol use as a lifestyle issue to be dealt with in the context of a holistic approach to patient care. Participants cited many barriers to fulfilling their role and were particularly concerned about the appropriateness of asking all adolescent and adult patients about alcohol use, even at visits intended to discuss other issues and concerns. Physicians gave several motivations for improving their work in reduction of alcohol consumption, including their current frustration with the lack of a systematic strategy or tangible materials to help them identify and manage patients. CONCLUSIONS: Interventions with patients who use alcohol should be framed in the context of a holistic approach to family medicine. Qualitative knowledge of the motivations and barriers affecting physicians can inform future research and educational strategies in this area.     

Community versus individual benefit

Australian law embodies a "communitarian" conception of the doctor's responsibility to respect the confidentiality of the doctor-patient relationship. This implies that respect for confidentiality sits alongside two other responsibilities: proper care for the patient's general wellbeing and proper attention to the safety of the community. Most jurisdictions now require drivers to advise their local driver-licensing authority of any permanent or long-term injury or illness that affects their ability to drive safely. Some jurisdictions require doctors to inform the driver-licensing authority about patients whose medical condition may impair their driving to the extent that they are likely to endanger the public. If you can not persuade a patient to inform the driver-licensing authority of the need for an assessment of his or her ability to drive safely, then you should inform the relevant authorities yourself.     

Managing erotic feelings in the physician-patient relationship.

In spite of prohibitions against the sexual involvement of physicians with their patients, erotic feelings sometimes arise in physician-patient relationships. The authors suggest that physicians can protect themselves and their patients from the harm that results from sexual involvement by establishing behavioural limits for their professional relationships, responding to patients' sexual overtures in a firm but nonjudgemental manner, examining their own sexual feelings rationally, seeking consultation if necessary and terminating the relationship if sexual feelings are compromising patient care. The challenge for physicians is to acknowledge that sexual feelings can arise and to manage such feelings for the sake of their own and their patients' well-being.     

Police and Criminal Evidence Bill and the BMA

The British Medical Association's efforts against controversial clauses in the pending Police and Criminal Evidence Bill have resulted in a government offer to amend legislation that would otherwise threaten the confidential nature of medical records and the physician patient relationship. The BMA maintains that if police were allowed complete access to medical records, treatment would be jeopardized because patients might withhold vital information from their physicians, and physicians would be reluctant to record potentially damaging information about their patients.     

Disclosing physician financial incentives

Federal and state regulatory initiatives as well as court decisions increasingly require managed care organizations to disclose physician financial incentives and have raised the issue of disclosure by physicians themselves. These mandates are based on ethical and legal principles arising from the patient-physician relationship and the relationship between health plan sponsors and enrollees. Disclosing incentives also serves important policy objectives: it can inform enrollees' choice of plan, reinforce enrollees' capacity to understand and exercise other rights under managed care, and discourage use of compensation methods that might compromise patients' access to treatment. However, significant conceptual and practical questions remain about implementing a disclosure mandate. Unresolved issues include the timing, content, and scope of disclosure, the relationship of disclosure to patients' substantive rights, and the impact of disclosure on trust between patients and physicians. These uncertainties exemplify the challenges facing policymakers, plans, and physicians as they determine how best to inform patients about managed care.     

Terminating pregnancy after prenatal diagnosis--with a little help of professional ethics?

Termination of pregnancy after a certain gestational age and following prenatal diagnosis, in many nations seem to be granted with a special status to the extent that they by law have to be discussed within a predominantly medical context and have physicians as third parties involved in the decision-making process ('indication-based' approach). The existing legal frameworks for indication-based approaches, however, do frequently fail to provide clear guidance for the involved physicians. Critics, therefore, asked for professional ethics and professional institutions in order to provide normative guidance for the physicians in termination of pregnancy on medical grounds. After outlining the clinical pathway in an indication-based approach and the involved types of (clinical) judgements, this paper draws upon different understandings of professional ethics in order to explore their potential to provide normative guidance in termination of pregnancy on medical grounds. The analysis reveals that professional ethics will not suffice-neither as a set of established norms nor as internal morality-in order to determine the normative framework of indication-based approaches on termination of pregnancy. In addition, there seem to be considerable inconsistencies regarding the target and outcome between prenatal testing on the one hand and following termination of pregnancy on the other hand. A source of morality external to medicine has to be the basis of evaluation if a consistent and workable normative framework for termination of pregnancy and prenatal testing should be established.     

Vaccination, consent and multidose vials

Multidose vials (MDVs) for injectable therapeutic agents, including vaccines, pose a risk of infection to injected patients as a result of contamination of the vials. The Australian Government Department of Health and Ageing (DoHA) distributed the vaccine against pandemic (H1N1) 2009 influenza in MDVs. The distribution was accompanied by consent forms. The consent forms provided an inadequate basis for a discussion with patients about the risks associated with the use of MDVs. The High Court of Australia has previously held that medical practitioners who fail to explain the material risks of medical procedures to their patients might be held liable in negligence for any adverse sequelae of the procedures, even if the risks are very low. Medical practitioners, nurses, medical indemnity insurers and the DoHA should prepare now for the probable future use of MDVs by developing a consent form that would provide a solid foundation for a discussion of material risks with patients seeking vaccination.     

The prevalence of drivers in acute geriatric wards.

An audit of 150 patients on five acute geriatric wards found that 28 (19%) still drove. Forty-three (28%) used to drive but had given up, whilst 79 (53%) (76 of whom were female) had never driven. Former drivers gave the main reason for stopping as cost. No driver could recall being advised about driving by a doctor. Twenty-two drivers (79%) had a significant clinical condition that could affect driving, ranging from blackouts to arthritis. It is recommended that all elderly patients should be asked if they drive and any clinical conditions they might have that would adversely affect their driving be sought. Appropriate advice should be given by doctors to their elderly patients in order to safeguard them and the public from road traffic accidents.     

Discrepancies between patient and physician estimates for the success of stem cell transplantation

CONTEXT: Stem cell transplantation is associated with considerable morbidity and mortality. The extent to which patients and their physicians correctly estimate these risks is unknown. OBJECTIVE: To measure the expectations of patients and physicians prior to stem cell transplantation and correlate them with actual outcomes after transplantation. DESIGN: Prospective cohort study with baseline questionnaire administered July 1996 through November 1999 and follow-up to May 2000. SETTING: Tertiary care transplant center in the United States. PARTICIPANTS: Of 458 surveys mailed, evaluable returned surveys were included for 313 autologous and allogeneic stem cell transplantation patients and their physicians. MAIN OUTCOME MEASURES: Patient and physician expectations prior to transplantation (measured on 6-point Likert scales) of treatment-related mortality, cure with transplantation, and cure without transplantation; actual treatment-related mortality and disease-free survival among patients with at least 1 year of follow-up after transplantation (n = 263). RESULTS: Both patients and physicians were fairly accurate in estimating treatment-related mortality when actual mortality was less than 30%. However, in situations in which mortality was higher than 30%, such as with allogeneic transplantation for intermediate or advanced disease, physician expectations were lower, while patients remained optimistic. Similarly, physicians provided lower estimates of disease-free survival in cases of intermediate or advanced disease while patient expectations remained high and constant regardless of disease stage. CONCLUSIONS: Patients and their physicians have the most concordant and accurate expectations when the outcome of stem cell transplantation is likely to be favorable. However, patients with more advanced disease fail to recognize the higher risks associated with their situations.     

重建医院伦理的制度因素建议——原则谈判法在医患关系分析中的应用

根据原则谈判的原理,医患关系紧张是医患利益冲突的立场表现,医患关系和谐化的出路在于通过制度调整,实现医患利益的相容。在医患关系的相关利益主体中,医生和患者是利益直接冲突的双方,而医院和政府则是利益关系的主导者。当制度能够保障医生的职业安全和应得利益,并且医生的职业安全和应得利益主要取决于患者的治疗疾病、可接受的医疗成本、受到应有的尊重等利益满足,那么医患关系和谐就会实现。达成这种局面的制度包括:提高医务人员与医院方的谈判地位、提供医务人员避免医疗风险的制度安排、加强对医生的执业水平和职业伦理的评价机制建设等方面的内容。     

A randomized trial to increase smoking intervention by physicians. Doctors Helping Smokers, Round I

Sixty-six physicians were randomized to three groups to conduct a 1-month campaign to help their patients stop smoking. The workshop group received free patient education materials and a 6-hour training workshop. The materials group received free patient education materials, and the no-assistance group received nothing. A telephone interview was completed with 89% of the 6767 eligible adult patients seen during the month of the campaign. The brief training program and patient education materials marginally increased the smoking intervention activities of volunteer physicians in private practice. Both workshop and materials physicians asked 54% of their smoking patients to stop; no-assistance physicians asked 40%. One year later, 36% of patients who had not even been asked by their doctors if they smoked reported that they had tried to stop smoking. If the physician had asked the patient if he or she smoked, the probability of a quit attempt was 47%. Patients who had been asked if they smoked were more likely to claim to have stopped (13%) than patients who had not been asked (9%). However, the proportion of patients claiming continued abstinence (range, 12% to 14%) was not related to the group of the physician.     

Medical decision making in scarcity situations

The issue of the allocation of resources in health care is here to stay. The goal of this study was to explore the views of physicians on several topics that have arisen in the debate on the allocation of scarce resources and to compare these with the views of policy makers. We asked physicians (oncologists, cardiologists, and nursing home physicians) and policy makers to participate in an interview about their practices and opinions concerning factors playing a role in decision making for patients in different age groups. Both physicians and policy makers recognised allocation decisions as part of their reality. One of the strong general opinions of both physicians and policy makers was the rejection of age discrimination. Making allocation decisions as such seemed to be regarded as a foreign entity to the practice of medicine. In spite of the reluctance to make allocation decisions, physicians sometimes do. This would seem to be only acceptable if it is justified in terms of the best interests of the patient from whom treatment is withheld.     

Professional recommendations: disclosing facts and values

It is not unusual for patients and their families, when confronted with difficult medical choices, to ask their physicians for advice. This paper outlines the shades of meaning of two questions frequently put to physicians: "What should I do?" and "What would you do?" It is argued that these are not questions about objective matters of fact. Hence, any response to such questions requires an understanding, appreciation, and disclosure of the personal context and values that inform the recommendation. A framework for considering and articulating a response to these questions is suggested, using as a heuristic the phrasing "If I were you.../If it were me..." Journal of Medical Ethics Key Words: Professional-patient relations ? informed consent ? truth disclosure ? ethics, medical     

（副）主任医师在病历质控中的主体作用

为了充分发挥（副）主任医师在病历质控中的主体作用。分析（副）主任医师查房中存在的主要问题,如查房中没有体现出应有的专业水平、未认真审阅下级医师书写的病历记录、忽视亲自向患者告知重要事项、甚至未能履行查房职责。应采取有效措施保证（副）主任医师在病历质控中的主体作用,如制定岗位职责、定期进行查房提出对诊断治疗的意见、审阅修改下级医师书写的病历记录等。从而提高临床诊疗水平与医疗安全。