Careful Words: Nursing,Language, and Emotion in Papua New Guinea

Papua New Guinean nurses work in a sociomedical system in which cultural and linguistic diversity are matters of pressing concern. Using data drawn from ethnographic research with PNG nursing students, I show how nursing education socializes nurses to take stances toward language and communication that impact their care practices. I argue that nurses’ use of language is shaped by their ethical commitments as educated Christians and indigenous concerns about the links between language, emotion, and health. In a resource-poor setting where health workers risk blame for structural inequalities, this “ethical metapragmatics” is an important but neglected facet of care work.     

Ethical issues in the managed care setting: a new curriculum for primary care physicians

Several challenging ethical issues have been associated with the shift to managed healthcare in the United States. Our objective was to develop, implement, and evaluate a curriculum designed to help physicians identify and examine ethical issues encountered in the managed care setting. The curriculum was developed during a year-long workshop at Johns Hopkins Bayview Medical Center. The content of the curriculum was established through literature review, focus group discussions with physicians, and a needs assessment of targeted learners (primary care physicians practicing in managed care settings). Some of the key issues addressed in the curriculum include: changing professional responsibilities of physicians; fair use of resources; and threats to the doctor-patient relationship as a consequence of the new healthcare delivery system. The 7.5-h curriculum was taught over five sessions using varied teaching methods. Evaluations demonstrated that the curriculum was successful in increasing learner awareness of ethical issues confronted in the managed care environment and improved learner knowledge in these areas. The physician-learners reported that this educational experience would change their teaching of medical students and residents. After completing the curriculum, learners felt that they were at least somewhat better able to cope with ethical challenges encountered in the managed care setting. Future research might examine whether such a curriculum could positively affect physician behavior or enhance physician satisfaction with the managed care setting.     

"It isn't just consultants that need a BSc": student experiences of an Intercalated BSc in primary health care

More medical schools are moving towards a compulsory intercalated BSc. These courses have not traditionally been aimed at those students interested in general practice and have tended to have limited clinical relevance. This paper explores the perceptions of students who undertook a BSc in primary health care using qualitative methodology comprising semi-structured interviews with students just before completion of their course. Interviews were undertaken with 24 of the 26 students who started the course over a 4-year period. All the students have finished the course and have graduated with good honours degrees. Students refine existing skills and develop new, relevant skills for medicine. The students discussed the prestige (or lack) of a BSc in this field and how the course has impacted on their career decisions. A Primary Health Care BSc such as this appears to give students an in depth and to some, a positive view of general practice and primary care. The course allowed students to develop a more critical approach to medicine and enabled them to develop skills in addition to those acquired from their undergraduate medicine course. They perceived that these skills will serve them throughout their career in whatever branch of medicine they choose.     

Power in the nursing home: the case of a special care unit

This article examines the effects and nature of power in a special care unit of a nursing home devoted to elders with dementia and/or disturbed behaviors. Drawing from two case studies and contemporary theories on power, I illustrate how the hierarchical structure of the clinic, together with the diffuseness and pervasiveness of disciplinary power, serves to shape the lives of--and to constrain the resistance opportunities open to--elders within the clinic. I also discuss the dilemma facing ethnographers of the clinic who may witness the sometimes disastrous effects of power but feel incapable, in their positions as researchers, of challenging the actions of clinical staff. At the same time, I observe how the contradictions of disciplinary power are often experienced by clinical staff who themselves struggle between taking actions they feel they must and those they would prefer. Far from acceding to the impotency that clinical anthropologists too often feel within a research setting, I argue that they can help to incite in their clinical colleagues the urgency of carrying out more productive alternatives to conventional "disciplinary" practices.     

Observations of physician, patient and family perceptions of informed consent in Houston, Texas

Informed consent is one of the most important ethical and legal principles in the United States, including Texas, and reflects a profound respect for individuals and their ability to make decisions in their own best interest. It is also a critical underpinning of medical practice, although how it is actually carried out has not been well studied. A survey was conducted in the private practices and a hospital in the Texas Medical Center in Houston, Texas to ascertain how physicians, patients and patient's family members perceive and demonstrate the elements of informed consent. In-depth interviews of twelve physicians, three patients and three family members were carried out. For physicians, consent was an explicit and implicit aspect of virtually all medical practice. Physicians would seek patient input concerning medical decisions whenever possible and might also discuss care choices with families. However, they often made decisions based upon what they perceived as the patient's best interests. Patients expected the physician to involve them in the decision process, but whether they turned to family members, or even others to assist them, varied considerably. Although Texas physicians respect the competent patient as the primary decision maker, they may bypass a formal surrogate decision maker to gain input from others, including their own view of what is in the patient's best interest.     

Physician perceptions of the role and value of basic science knowledge in daily clinical practice

Background: The role of basic science education in a clinical setting remains unclear. Research to understand how academic clinicians perceive and use this part of their education can aid curricular development. Aims: To assess physician's attitudes toward the value of science knowledge in their clinical practice. Methods: Academic physicians from three medical schools completed a questionnaire about the utility of basic science education in core clinical tasks and in practice-based learning and improvement. Results: A total of 109 clinical faculty returned the survey. Overall, 89% of the respondents indicated that basic science education is valuable to their clinical practice. When asked about the utility of basic science information in relation to direct patient care, greater than 50% of the doctors felt they use this when diagnosing and communicating with patients. This rose to greater than 60% when asked about choosing treatment options for their patients. Individuals also responded that basic science knowledge is valuable when developing evidence-based best practices. Specifically, 89% felt that they draw upon this information when training students/residents and 84% use this information when reading journal articles. Conclusions: This study shows that basic science education is perceived by responding academic physicians to be important to their clinical work.     

Ethical Use of Social Media Data: Beyond the Clinical Context

In “Social Media, e‐Health, and Medical Ethics,” in this issue of the Hastings Center Report, Mélanie Terrasse, Moti Gorin, and Dominic Sisti address and suggest recommendations for several ethical issues central to the systematic ethical analysis of the effects of social media on clinical practice, health services research, and public health. The topic is as timely as it is important: social media data collected by device and web applications are constantly increasing and might have both individual and public health benefits. The authors focus their analysis primarily on the health care context. Yet the implications of the intersection of social media data and research warrant focused consideration, as even the most thorough ethical analysis in the clinical context is not necessarily directly applicable in the research context. While many ethical issues are present in both settings, the research context poses new challenges and calls for consideration of distinct factors. In particular, because the legal framework is less protective in research, critical ethical analysis of the research‐specific issues and considerations is essential to the ethical conduct of research using social media data as well as to the design and operation of social media device and web applications themselves.     

Medical education in the public versus the private setting: a qualitative study of medical students' attitudes

Public hospitals serve as primary training sites for medical students. Public patients may therefore bear a disproportionate burden of medical student education. The purpose of this study was to critically examine the ethics of medical education in the public setting. Attitudes of first- and fourth-year students towards the role of public patients in medical education were elicited in focus groups. Inductive qualitative analysis was utilized to organize data into conceptual groups, which were then analyzed within an ethical framework. All patients have an equal obligation to participate in medical education. Students identified modifying factors that could affect a patient's obligation to educate future physicians. Available data highlight a concern that public teaching hospitals may provide a lower quality of care. If true, then the public teaching setting is creating an unfair burden upon that patient population who would then have a weakened obligation to participate in medical education.     

Clinical Trial Portfolios: A Critical Oversight in Human Research Ethics,Drug Regulation,and Policy

Regulators rely on clinical trials for drug approval and labeling decisions. Health systems and clinicians rely on the evidence from trials to determine treatment, and patients rely on it to decide which courses of care to undertake. Many of these stakeholders presume that the careful review of individual studies is enough to address the ethical and scientific questions that arise in clinical trials. In what follows, however, we demonstrate that explicit consideration of trial portfolios—series of trials that are interrelated by a common set of objectives—is crucial. the ethical acceptability and evidentiary probity of individual trials can change depending on the characteristics of the portfolios in which they are embedded. Second, how trial portfolios are composed, how well they are coordinated, and how efficiently they use information determines the balance of risks and benefits they present as well as their different prospects for generating socially valuable information; these three factors also raise distinct questions of justice.     

The Problem of Clinical Deception and Why We Cannot Begin in the Middle

In this brief commentary, I offer an appreciative yet critical analysis of Abram Brummett and Erica Salter's article, “Mapping the Moral Terrain of Clinical Deception.” I challenge the authors to clarify their choice of the term “deception” (as opposed to “lying” or “dishonesty”), and I explain how these different terms may affect one's moral analysis. I also draw attention to the authors’ claim that veracity is the ethical default of clinicians. I argue that their failure to defend this claim renders their framework more limited in its usefulness than they seem to acknowledge. While their framework does an excellent job of identifying morally salient features of clinical deception, it cannot be used to measure the strength of justification for an act of deception apart from a normative conception of truthfulness.     

Serving the emperor without asking: critical care ethics in Japan

This article is an attempt by Japanese physicians to introduce the practice patterns and moral justification of Japanese critical care to the world. Japanese health care is characterized by the fact that the fee schedule does not reward high technology medicine, such as surgery and critical care. In spite of the low reimbursement, our critical care practice pattern is characterized by continuing futile treatment for terminal patients in the intensive care unit (ICU). This apparently wasteful practice can be explained by fundamental Japanese cultural values, social factors in Japan, the availability of extensive insurance coverage, physicians' psychological factors, lack of cost-benefit considerations and the pragmatic approach the Japanese take to situations. We attempt to make some brief suggestions regarding the improvement of our critical care practices. Although we can not fully present quantitative data to support our argument, this article represents our real-world approaches to the ethical issues in the ICU in Japan.     

Canada's non-status immigrants: negotiating access to health care and citizenship

Illegal immigration in Canada is characterized mainly by non-status immigrants who legally enter Canada and stay after their legal status expires and by failed refugee claimants. For these persons, immigration status or its absence plays an important role in determining the degree of access to Canadian health care. This article situates the clinical setting as a site of contention and negotiation of citizenship and care in social networks as well as pragmatic and discursive strategies. Drawing on the case of a patient who faced imminent deportation and became suicidal, in this article I depict how psychiatrists and other health practitioners embrace "bearing witness" as an ethical practice, which intersects the medical and legal spheres.     

Introducing undergraduate medical teaching into general practice: an action research study

Following the publication of Tomorrow's Doctors and as a result of increasing numbers of students recruited to medical school it is necessary to involve more general practitioners (family physicians) in undergraduate medical education. Students have responded positively regarding experiences in general practices with a broad spectrum of clinical conditions to be seen and greater involvement in clinical decision-making. This action research study followed a small group general practice in South Wales through the required preparation for undergraduate medical education and its first year of teaching. Preparatory work for the practice focused mainly on summarizing patient notes, setting up a practice library and arranging accommodation for the students. Members of the Primary Health Care Team (PHCT) found that having students in the practice gave them a sense of achievement and enhanced self-worth. Individuals within the practice felt more confident in their professional role and the team ethic within the practice was strengthened. Doctors' anxieties regarding the adequacy of their clinical skills proved unfounded. Patients were reported to feel more included in their care and to have enjoyed hearing their condition being discussed with the students. Students valued the one-to-one teaching, seeing common illnesses and a variety of consulting styles. It is hoped that this paper will be of value to those responsible for recruiting GP practices into undergraduate teaching. It demonstrates benefits for the primary health care team in terms of improved morale and sense of professional self-worth. Patients felt more involved in their care. Generalization from these findings is limited by only one practice having been involved. Undergraduate teaching offers advantages, particularly in terms of professional self-esteem and team morale.     

On the triad disease,illness and sickness

The point of departure for this article is a review of the discussion between Twaddle and Nordenfelt on the concepts of disease, illness, and sickness, and the objective is to investigate the fruitfulness of these concepts. It is argued that disease, illness, and sickness represent different perspectives on human ailment and that they can be applied to analyze both epistemic and normative challenges to modern medicine. In particular the analysis reveals epistemic and normative differences between the concepts. Furthermore, the article demonstrates, against Nordenfelt's claim, that the concepts of disease, illness, and sickness can exist without a general theory of health. Additionally, the complexity of different perspectives on human ailment also explains why it is so difficult to give strict definitions of basic concepts within modern health care.     

Ethical challenges in critical care medicine: a Chinese perspective

The major ethical challenges for critical care medicine in China include the high cost of patient care in the ICU, the effect of payment mechanisms on access to critical care, the fact that much more money is spent on patients who die than on ones who live, the extent to which an attempt to rescue and save a patient is made, and the great geographical disparity in distribution of critical care. The ethical problems surrounding critical care medicine bear much relation to the culture, public policy and health care system in China. The essay concludes that China should allocate more resources to ordinary medical services rather than to critical care medicine.     

Deception and Distress

In the lead article in the January-February 2023 issue of the Hastings Center Report, Abram Brummett and Erica Salter provide a conceptual framework to help physicians think through the ethics of deceiving a patient or someone closely connected to the patient. Brummett and Salter identify four main ethical features of any act of clinical deception and elaborate on how, in a given case, these features together influence the degree to which a deception could be justified. A second article in this issue presents an ethnographic study of the effect of the Covid-19 pandemic on critical care workers in an intensive care unit. The authors describe a level and form of moral distress that, they argue, goes beyond what the term “moral distress” captures. The authors offer “distressed work” to better mark the broad consequences for care workers’ roles, occupations, and vocations.     

Bluffing, puffing and spinning in managed-care organizations

I argue that because bluffing, puffing, and spinning are features of corporate life, they are likely to characterize the doctor-patient relationship in managed care medicine. I show that managed-care organizations (MCOs) and the physicians who contract with them make liberal use of puffing and spinning. In this way, they create a context in which it is likely that patients will also use deceptive mechanisms. Unfortunately, patients risk their health when they deceive their doctors. Using the warranty theory of truth I argue that although bluffing may be ethical in business because all participants agree to it and business has not warranted truth-telling, it is not ethical in a medical context because physicians and MCOs have warranted truth-telling and the quality of medical care depends on it.     

Reconceptualizing Autonomy: A Relational Turn in Bioethics

History's judgment on the success of bioethics will not depend solely on the conceptual creativity and innovation in the field at the level of ethical and political theory, but this intellectual work is not insignificant. One important new development is what I shall refer to as the relational turn in bioethics. This development represents a renewed emphasis on the ideographic approach, which interprets the meaning of right and wrong in human actions as they are inscribed in social and cultural practices and in structures of lived meaning and interdependence; in an ideographic approach, the task of bioethics is to bring practice into theory, not the other way around. The relational turn in bioethics may profoundly affect the critical questions that the field asks and the ethical guidance it offers society, politics, and policy. The relational turn provides a way of correcting the excessive atomism of many individualistic perspectives that have been, and continue to be, influential in bioethics. Nonetheless, I would argue that most of the work reflecting the relational turn remains distinctively liberal in its respect for the ethical significance of the human individual. It moves away from individualism, but not from the value of individuality.In this review essay, I shall focus on how the relational turn has manifested itself in work on core concepts in bioethics, especially liberty and autonomy. Following a general review, I conclude with a brief consideration of two important recent books in this area: Jennifer Nedelsky's Law's Relations and Rachel Haliburton's Autonomy and the Situated Self.     

Loyalty in the trenches: practical teleology for office clinicians responding to terrorism

Were terrorists ever to effectively deploy weapons of mass destruction, medical practice would be quickly transformed. Many ordinary clinicians would be asked or required to treat unfamiliar yet serious medical conditions in a setting of overwhelming urgency and impossible odds. Clinical focus would shift from doing good things for a succession of individual patients to considering many patients at once, a change that could beget loss of trust and rapport with patients. Clinicians might also experience restrictions in personal liberties and appropriation of their property. The purpose of this essay is to develop a teleological framework for undertaking this transformation. In ordinary clinical medicine, the elusiveness of the individual telos (i.e.,the good for the individual) is acknowledged in procedures (such as social history taking,informed consent and outpatient scheduling) designed to protect patients' (and clinicians')prerogatives to interpret the telos for themselves. In mass casualty scenarios, on the other hand, the telos is standardized and regarded as an Immediate Object (usually as a state of affairs in which survival is maximized and permanent disability is minimized). Clinicians who provide mass casualty care will face a number of ethical challenges that can be negotiated by appealing to the political and ethical rationale, and limits, pertaining to the pursuit of aggregate survival as an Immediate Object.     

The Real‐World Ethics of Adaptive‐Design Clinical Trials

From the earliest application of modern randomized controlled trials in medical research, scientists and observers have deliberated the ethics of randomly allocating study participants to trial control arms. Adaptive RCT designs have been promoted as ethically advantageous over conventional RCTs because they reduce the allocation of subjects to what appear to be inferior treatments. Critical assessment of this claim is important, as adaptive designs are changing medical research, with the potential to significantly shift how clinical trials are conducted. Policy‐makers are swiftly moving to encourage greater use of adaptive designs. In 2016, the newly enacted 21st Century Cures Act instructed the Food and Drug Administration to help product sponsors incorporate adaptive methods into proposed clinical trial protocols and applications for investigational drugs and also biological products. In this article, we review the ethical justifications commonly offered for adaptive designs, explore these arguments in the context of actual trials, and contend that clinical equipoise is a useful standard for adaptive‐trial ethics. We distinguish between theoretical and clinical equipoise and explain why ethical arguments related to adaptive trials tend to focus on the former. Yet we contend that theoretical equipoise can be an unreliable standard for adaptive ethics. While we contend that clinical equipoise is the most critical principle for the primary ethical concerns posed by adaptive trials, we suggest ethical approaches to deal with some additional concerns unique to adaptive designs.