The Council on Ethical and Judicial Affairs of the American Medical Association examines physicians’ professional ethical responsibility in the event that the security of patients’ electronic records is breached.

Using the theoretical constructs “biographical disruption” and “limit experience” and also methodological frameworks from autoethnography and discourse analysis, we discuss the divergent ways in which language and healing are conceptualized and performed, first in an American medical clinic and then by traditional healers in Kwara‘ae (Solomon Islands). Discourses at the Dallas clinic draw on allopathic and complementary medicine and in emphasizing a scientific approach to talk about illness and treatment, were found to create ambiguity in patients’ (...) sense of their physical and metaphysical identities. In contrast, Kwara‘ae healing involves disappearing into silence, in which the physical and metaphysical are never separated, and where healing occurs. (shrink)

In 1972, I created the new field of clinical medical ethics (CME) in the Department of Medicine at the University of Chicago. In my view, CME is an intrinsic part of medicine and is not a branch of bioethics or philosophical ethics or legal ethics. The relationship of patients with medically trained and licensed clinicians is at the very heart of CME. CME must be practiced and applied not by nonclinical bioethicists, but rather by licensed clinicians in their routine, (...) daily encounters with inpatients and outpatients. CME addresses many clinical issues such as truth-telling, informed consent, confidentiality, surrogate decision making, and end-of-life care, while also encouraging personal, humane, and compassionate interactions between experienced clinicians and patients.The goals of CME are to improve patient care and outcomes by helping physicians and other health professionals Clinical Medical Ethics: Its History and Contributions to American Medicine Mark Siegler, Guest Editor identify and respond to clinical-ethical challenges that arise in the ordinary care of patients. As Edmund Pellegrino, Peter A. Singer, and I wrote in the first issue of The Journal of Clinical Ethics, 30 years ago: “The central goal of CME is to improve the quality of patient care by identifying, analyzing, and contributing to the resolution of ethical problems that arise in the routine practice of clinical medicine.” Similar to cardiology and oncology consultations, ethics consultations are a small component of a much larger field, and the process of consultations is certainly not at the core of cardiology or oncology or CME.In this article, I intend to discuss the origins of the field of CME, its goals and methods, the relationship between the broad field of CME and the much narrower practice of ethics consultation, the contributions of the MacLean Center at the University of Chicago in developing the field of CME, and, finally, how CME has improved the practice of medicine in the United States. (shrink)

The Association of American Medical Colleges (AAMC) is urging academic medical centers to ban pharmaceutical detailing. This policy followed from a consideration of behavioral and neuroeconomics research. I argue that this research did not warrant the conclusions drawn from it. Pharmaceutical detailing carries risks of cognitive error for physicians, as do other forms of information exchange. Physicians may overcome such risks; those determined to do so may ethically engage in pharmaceutical detailing. Whether or not they should do (...) so is a prudential judgment about which reasonable people may disagree. The AAMC's ethical condemnation of detailing is unwarranted and will subvert efforts to maintain a realm of physician discretion in clinical work that is increasingly threatened in our present practice environment. (shrink)

This article presents a radical claim: American medical ethics is broken, and it needs love to be healed. Due to a unique set of cultural and economic pressures, American medical ethics has adopted a mechanistic mode of ethical reasoning epitomized by the doctrine of principlism. This mode of reasoning divorces clinicians from both their patients and themselves. This results in clinicians who can ace ethics questions on multiple‐choice tests but who fail either to recognize a patient's (...) humanity or to navigate the ethical quandaries into which they are frequently thrown. Drawing on personal experience as well as the philosophical work of Augustine of Hippo, Simone Weil, and Iris Murdoch, we propose a novel ethical approach grounded in a conception of neighbor love, specifically, the virtue of love understood as attention to a sufferer's humanity. We conclude with five practical recommendations for reimagining medical ethics education oriented around the virtue of love. (shrink)

As practicing clinicians, physicians are expected to uphold the ethical norms of their profession, including fidelity to patients and respect for patients’ self-determination. At the same time, as individuals, physicians are moral agents in their own right and, like their patients, are informed by and committed to diverse cultural, religious, and philosophical traditions and beliefs. In some circumstances, the expectation that physicians will put patients’ needs and preferences first may be in tension with the need to sustain the sense of (...) moral integrity and continuity that grounds a physician’s personal and professional life. This article examines the implications for patients, physicians, and the medical profession when tensions arise between a physician’s professional commitments and his or her deeply held personal moral beliefs. It offers guidance on when a physician’s professional commitments should outweigh personal beliefs as well as when physicians should have freedom to act according to the dictates of conscience while still protecting patients’ interests. (shrink)

Chasing Medical Miracles" is the first book to give readers a behind-the-scenes look at the complicated world of clinical trials, revealing how a multibillion-dollar industry of private companies conducting them with little oversight has taken root and quietly become a major part of the American medical establishment.

American Academy of Pediatrics (AAP) and American College of Medical Genetics (ACMG) recently provided two recommendations about predictive genetic testing of children. The Clinical Sequencing Exploratory Research Consortium's Pediatrics Working Group compared these recommendations, focusing on operational and ethical issues specific to decision making for children. Content analysis of the statements addresses two issues: (1) how these recommendations characterize and analyze locus of decision making, as well as the risks and benefits of testing, and (2) whether the (...) guidelines conflict or come to different but compatible conclusions because they consider different testing scenarios. These statements differ in ethically significant ways. AAP/ACMG analyzes risks and benefits using best interests of the child and recommends that, absent ameliorative interventions available during childhood, clinicians should generally decline to order testing. Parents authorize focused tests. ACMG analyzes risks and benefits using the interests of the child and other family members and recommends that sequencing results be examined for additional variants that can lead to ameliorative interventions, regardless of age, which laboratories should report to clinicians who should contextualize the results. Parents must accept additional analysis. The ethical arguments in these statements appear to be in tension with each other. (shrink)

Volume 25, Issue 2, February 2025, Page 23-25.

:Academic Medical Centers offer patient care and perform research. Increasingly, AMCs advertise to the public in order to garner income that can support these dual missions. In what follows, we raise concerns about the ways that advertising blurs important distinctions between them. Such blurring is detrimental to AMC efforts to fulfill critically important ethical responsibilities pertaining both to science communication and clinical research, because marketing campaigns can employ hype that weakens research integrity and contributes to therapeutic misconception and misestimation, (...) undermining the informed consent process that is essential to the ethical conduct of research. We offer ethical analysis of common advertising practices that justify these concerns. We also suggest the need for a deliberative body convened by the Association of American Medical Colleges and others to develop a set of voluntary guidelines that AMCs can use to avoid in the future, the problems found in many current AMC advertising practices. (shrink)

The dilemma of incapacitated patients with acute medical problems who want or try to leave the hospital is a common problem in American clinical ethics. One need only listen to clinicians who work...

Clinical ethics consultation is largely outside the scope of regulation and oversight, despite its importance. For decades, the bioethics community has been unable to reach a consensus on whether there should be accountability in this work, as there is for other clinical activities that influence the care of patients. The American Society for Bioethics and Humanities, the primary society of bioethicists and scholars in the medical humanities and the organizational home for individuals who perform CEC in the United (...) States, has initiated a two‐step quality attestation process as a means to assess clinical ethics consultants and help identify individuals who are qualified to perform this role. This article describes the process. (shrink)

BackgroundFew comparative studies of clinical ethics consultation practices have been reported. The objective of this study was to explore how American and Japanese experts analyze an Alzheimer's case regarding ethics consultation.MethodsWe presented the case to physicians and ethicists from the US and Japan (one expert from each field from both countries; total = 4) and obtained their responses through a questionnaire and in-depth interviews.ResultsEstablishing a consensus was a common goal among American and Japanese participants. In attempting to achieve (...) consensus, the most significant similarity between Japanese and American ethics consultants was that they both appeared to adopt an "ethics facilitation" approach. Differences were found in recommendation and assessment between the American and Japanese participants. In selecting a surrogate, the American participants chose to contact the grandson before designating the daughter-in-law as the surrogate decision-maker. Conversely the Japanese experts assumed that the daughter-in-law was the surrogate.ConclusionOur findings suggest that consensus building through an "ethics facilitation" approach may be a commonality to the practice of ethics consultation in the US and Japan, while differences emerged in terms of recommendations, surrogate assessment, and assessing treatments. Further research is needed to appreciate differences not only among different nations including, but not limited to, countries in Europe, Asia and the Americas, but also within each country. (shrink)

Clinical bioethics plays a significant role in hospital settings through bioethics consultations, which focus on providing ongoing assistance in complex situations within the doctor-patient dynamic. These consultations entail regular interaction between physicians and clinical bioethicists. This situation prompts an exploration into how bioethics consultations affect physicians. The current research aims to understand the influence of bioethics consultations on physicians’ bioethical knowledge by analyzing the lexical content in their patients’ medical records. Medical records are a synthesis carried out by (...) physicians, often reflecting collaborative efforts, and capturing verbal statements indicative of thought processes suggestive of learning. The study is a sequential mixed-methods design with a retrospective descriptive approach, comparing medical records from the early years of the Department of Humanism and Bioethics’ operation (2013–2015) to the more recent ones (2019). Technical bioethical terminology such as “therapeutic effort limitation,” “futility,” “beneficence,” and “respect for autonomy” is more prevalent in recent medical records. This trend may stem from the positive impact of bioethics consultations conducted by the Department, with haptic communication serving as a particularly effective form of interaction with others during experiences of moral distress. This appears to be characteristic of cultures like those in Latin America. (shrink)

sirThe American University of Beirut was established in the last decade of the 19th century and is the only one of three current medical programmes in Lebanon to adopt American curricular standards and English as a language of instruction. A formal course in medical ethics was introduced in 1994, which instructs students in the third year on issues such as truth-telling to patients, within the context of the “paternalism versus autonomy” debate.1–4 Changes of attitude toward cancer (...) disclosure following the introduction of that formal course were measured serially in the same class of AUB medical students as they moved from the first to the fourth medical years. In that four-year interval, students graduated from theoretical courses to clinical contact with patients.Seventy students …. (shrink)

Individuals each have their own unique conceptions of what is good. Nevertheless, because human beings have common needs, there is a significant overlap in their appreciation of what counts as good...

IntroductionDespite the need for trained physician ethicists, fellowships in clinical ethics are limited and primarily offered to thosewho have completed a graduate degree. The standardization of credentialing for clinical ethics consultants (CECs) and the restructuring of undergraduate medical education allow innovative models to train CECs that can provide an expanded opportunity for formal ethics training at an earlier stage.MethodsAt the University of Michigan Medical School we developed, implemented, and evaluated a pre-doctoral clinical ethics fellowship program from 2017 to (...) 2019 for senior medical students, designed to meet established competencies for CECs. Consultation notes from the beginning and end of the fellowship program were randomly selected for each fellow and independently rated by two faculty ethicists who used the validated Ethics Consultation Quality Assessment Tool (ECQAT).1 Inter rater reliability and trends in scores over time were calculated.ResultsThree students successfully completed the fellowship at the University of Michigan Medical School, conducted at least 50 formal ethics consultations, and spent approximately 40 hours a week on service for a minimum of six months. All students finished the fellowship with teaching and policy development experience, first-authored peer-reviewed manuscripts, and national presentations. The fellows demonstrated improvement in their ECQAT overall holistic rating score; all ended their fellowship with a holistic score of adequate or above. There was 92 percent agreement between raters withrespect to the acceptability of the fellows’ ethics consult notes. Two fellows have taken and passed the Healthcare Ethics Consultant-Certification (HEC-C) exam offered by the American Society for Bioethics and Humanities (ASBH).ConclusionsIntegration of a pre-doctoral fellowship model that meets professional certification standards for clinical ethics consultation creates an opportunity for medical students to become trained CECs early in their career. (shrink)

There is a palpable malaise in American medicine as clinical practice veers off its moorings, swept along by a new commercialism that is displacing medical professionalism and its attendant moral obligations. Although the sociology of this phenomenon is complex and multifactorial, I argue that this move toward medical commercialism was accelerated by the abortive efforts of the Clinton Administration's Health Security Act. Through an analysis of performative speech I show that, although the Clinton plan drew on many (...) strands of speech about healthcare, it favored the discourse of health policy and health economics over that of clinical practice and professionalism. Though the Clinton plan failed, this new vocabulary of health economics has led us to imagine a new descriptive framework, which has commodified healthcare and commercialized the clinic. (shrink)

In their target article, Moore and colleagues offer a valuable overview of the various ambivalence-related phenomena that may impede swift clinical decision-making. They argue that patients...

This paper describes one possible origin point for fraudulent behavior within the American pharmaceutical industry. We argue that during the late nineteenth century therapeutic reformers sought to promote both laboratory science and increasingly systematized forms of clinical experiment as a new basis for therapeutic knowledge. This process was intertwined with a transformation in the ethical framework in which medical science took place, one in which monopoly status was replaced by clinical utility as the primary arbiter of pharmaceutical legitimacy. (...) This new framework fundamentally altered the set of epistemic virtues—a phrase we draw from the philosophical field of virtue epistemology—considered necessary to conduct reliable scientific inquiry regarding drugs. In doing so, it also made possible new forms of fraud in which newly emergent epistemic virtues were violated. To make this argument, we focus on the efforts of Francis E. Stewart and George S. Davis of Parke, Davis & Company. Therapeutic reformers within the pharmaceutical industry, such as Stewart and Davis, were an important part of the broader normative and epistemic transformation we describe in that they sought to promote laboratory science and systematized clinical trials toward the twin goals of improving pharmaceutical science and promoting their own commercial interests. Yet, as we suggest, Parke, Davis & Company also serves as an example of a company that violated the very norms that Stewart and Davis helped introduce. We thus seek to describe one possible origin point for the widespread fraudulent practices that now characterize the pharmaceutical industry. We also seek to describe an origin point for why we conceptualize such practices as fraudulent in the first place. (shrink)

It is unknown to what extent medical researchers generalize study findings beyond their samples when their sample size, sample diversity, or knowledge of conditions that support external validity do not warrant it. It is also unknown to what extent medical researchers describe their results with precise quantifications or unquantified generalizations, i.e., generics, that can obscure variations between individuals. We therefore systematically reviewed all prospective studies (n = 533) published in the top four highest ranking medical journals, Lancet, (...) New England Journal of Medicine (NEJM), Journal of the American Medical Association (JAMA), and the British Medical Journal (BMJ), from January 2022 to May 2023. We additionally reviewed all NEJM Journal Watch clinical research summaries (n = 143) published during the same time. Of all research articles reporting prospective studies, 52.5% included generalizations beyond specific national study populations, with the numbers of articles with generics varying significantly between journals (JAMA = 12%; Lancet = 77%) (p < 0.001, V = 0.48). There was no evidence that articles containing broader generalizations or generics were correlated with larger or more nationally diverse samples. Moreover, only 10.2% of articles with generalizations beyond specific national populations reported external validity strengthening factors that could potentially support such extrapolations. There was no evidence that original research articles and NEJM Journal Watch summaries intended for practitioners differed in their use of broad generalizations, including generics. Finally, from the journal with the highest citation impact, articles containing broader conclusions were correlated with more citations. Since there was no evidence that studies with generalizations beyond specific national study populations or with generics were associated with larger, more nationally diverse samples, or with reports of population similarity that may permit extensions of conclusions, our findings suggest that the generalizations in many articles were insufficiently supported. Caution against overly broad generalizations in medical research is warranted. (shrink)

Can machine intelligence do clinical ethics? And if so, would applying it to actual medical cases be desirable? In a recent target article (Meier et al. 2022), we described the piloting of our advisory algorithm METHAD. Here, we reply to commentaries published in response to our project. The commentaries fall into two broad categories: concrete criticism that concerns the development of METHAD; and the more general question as to whether one should employ decision-support systems of this kind—the debate we (...) set out to ignite with our target article. (shrink)

Medical cannabis is widely available in the USA and legalisation is likely to expand. Despite the increased accessibility and use of medical cannabis, physicians have significant knowledge gaps regarding evidence of clinical benefits and potential harms. We argue that primary care providers have an ethical obligation to develop competency to provide cannabis to appropriate patients. Furthermore, specific ethical considerations should guide the recommendation of medical cannabis. In many cases, these ethical considerations are extensions of well-established principles of (...) beneficence and nonmaleficence, which indicate that providers should recommend cannabis only for conditions that have the strongest evidence base. Additionally, the contested status of cannabis in American culture raises specific issues related to shared decision-making and patient education, as well as continuing clinical education. (shrink)

Among medical researchers and clinicians the dominant view is that it is unethical to deceive patients by prescribing a placebo. This opinion is formalized in a recent policy issued by the American Medical Association (AMA [Chicago, IL]). Although placebos can be shown to be always safe, often effective, and sometimes necessary, doctors are now effectively prohibited from using them in clinical practice. I argue that the deceptive administration of placebos is not subject to the same moral objections (...) that face other forms of deception in clinical practice and medical research. Although deception is normally objectionable on the grounds that it limits autonomy and breaches trust, these grounds do not apply to placebos when they are prescribed within appropriate ethical limits. Patients have reason to prefer that doctors can prescribe placebos in ethically responsible ways. Hence, the AMA has an obligation to endorse and to promote the responsible use of deceptive placebos in clinical practice. (shrink)

The American Medical Association's Code of Ethics prohibits physicians from giving substances they believe are placebos to their patients unless the patient is informed of and agrees to use of the substance. Various questions surround the AMA policy, however. One of these has to do with what should be disclosed. The AMA holds that any treatment that the physician believes is a placebo should be identified as such to the patient. But consider a more restrictive policy that requires (...) physicians to defer to the medical community's consensus view about which treatments have a specific effect on the condition being treated. In light of the ethical goals that the AMA identifies—namely, concerns about patient trust, autonomy, and benefit—there are potential advantages to the more restrictive policy. (shrink)

This essay is a critique of medical/clinical ethics from the personal perspective of a medical historian in an academic health science centre who has interacted with ethicists. It calls for greater transparency and accountability of ethicists involved in ‘bedside consulting;’ it questions the wisdom of the four principles of biomedical ethics and their American cultural origins with respect to training; challenges the authority of ‘core competencies’ for ethicists as identified by the American Society for Bioethics and (...) Humanities; and muses over the apparent reintroduction of religion into clinical medicine through the medium of bioethics. This essay is designed to provoke reflection on the putative ‘professionalism’ of the consulting ethics enterprise for which educational baselines and curricula are not standardized. By analysing sources such as the professional material communicated by the Canadian Bioethics Society, it also critiques the collective ethical shortcoming... (shrink)

Managed care employs two business tools of managed practice that raise important ethical issues: paying physicians in ways that impose conflicts of interest on them; and regulating physicians' clinical judgment, decision making, and behavior. The literature on the clinical ethics of managed care has begun to develop rapidly in the past several years. Professional organizations of physicians have made important contributions to this literature. The statements on ethical issues in managed care of four such organizations are considered here, the (...) class='Hi'>American Medical Association, the American College of Physicians, the American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics. Three themes common to these statements are identified and critically assessed: the primacy of meeting the medical needs of each individual patient; disclosure of conflicts of interest in how physicians are paid; and opposition to gag orders. The paper concludes with an argument for a basic concept in the clinical ethics of managed care: physicians and institutions as economically disciplined moral co-fiduciaries of populations of patients. (shrink)

*The views expressed are the author's own. This article should not be construed as representing policies of the American Medical Association.

In lieu of an abstract, here is a brief excerpt of the content:The Foundation of Ethical Theory in the ClinicJohn Collins Harvey (bio)William Osler has had a very profound and lasting effect on American medical education and medical practice. He set the pattern, still followed today, for the clinical training of medical students at the patient’s bedside and in the clinical laboratory. In such settings Osler was able to demonstrate to his pupils the principles, ethics, and (...) standards of medical practice that he espoused and thought fundamental to the profession of medicine. His monumental text book, The Principles and Practice of Medicine, first published in 1892, transformed the medical profession and remained a standard text for more than four decades (Leon 1995, p. 13). Renowned medical historians, such as Pedro Laín Entralgo, Henry Sigerist, and Richard Shyrock, recognize him as the greatest clinician that North America has ever produced.Osler, who had observed bedside teaching in his post-graduate studies, recognized that this method had much to offer in the instruction of medical students. Opportunity to introduce this method of teaching into the medical school curriculum came in 1888 when he was called to serve as Professor of Medicine and Physician-in-Chief at the newly established Johns Hopkins Medical School and Hospital. Bedside teaching proved to be very successful especially in demonstrating to students the standards and ethics of medical practice that he espoused.Osler’s teaching method was immediately adopted by many of the university medical schools in the United States, including Harvard, Columbia, the University of Pennsylvania, and Stanford, all of whom appreciated the success of the Hopkins medical educational experiment. Graduates of the Hopkins Medical School quickly became a major source of faculty in medical schools in the United States. Many of Osler’s immediate pupils became outstanding clinicians and leaders in American academic medicine and served as faculty members at Hopkins or in established or newly founded schools. Osler’s disciples taught students in the wards the “art” of medicine according to his principles, ethics, and standards. The second and third generation faculty members, who were trained by Osler’s immediate pupils, continue to this day to teach the “art” by employing this method of teaching. Consequently, the practice of medicine in the United States continues to be influenced by the ethics held by Osler. To find [End Page 343] the theories behind Osler’s teaching, we must look at Osler’s background, education, and writings.The Religio Medici: Background For Osler’S Medical EthicsOsler received a very solid traditional classical education at the small, excellent Anglican secondary school in Weston, Ontario run by the Reverend James Johnson, with whom Osler developed a life long friendship. Johnson’s avocation was natural science. He first aroused Osler’s interest in nature and science. Osler was taught Scripture well at Weston. He committed much of the Bible to memory and often quoted it in his speeches. He also studied both Greek and Latin, and was exposed to the writings of Plato, Aristotle, Cicero, and other classical authors, particularly the stoics.While a student at Weston, Osler first came to know Sir Thomas Browne’s remarkable text Religio Medici (The Religion of the Physician), which was to become a lifelong favorite. In his first address as the new Regius Professor of Medicine at Oxford in 1905, which was given to the Guy’s Hospital Physical Society, he vigorously recommended the Religio Medici to the students.The Religio is a deeply reflective personal inquiry into the paradoxical nature of one man as a microcosm of all men (Browne 1940, pp. 40, 53–54, 61–62). Browne participated in the Baconian program for the advancement of knowledge and the rise of “science.” As a defense of the physician’s faith, the Religio shows how neatly the scientist and the Christian united in the single figure of the inspired reader of God’s two books, nature and Scripture, can defend an attitude that is both scientific and yet reverent. The central theme in the first and much longer part of the Religio is the relation between faith and reason. The second part of the Religio is about charity: Man’s love of God and his neighbors, commanded as... (shrink)

Background: Patient autonomy has been promoted as the most important principle to guide difficult clinical decisions. To examine whether practising physicians indeed value patient autonomy above other considerations, physicians were asked to weight patient autonomy against three other criteria that often influence doctors’ decisions. Associations between physicians’ religious characteristics and their weighting of the criteria were also examined. Methods: Mailed survey in 2007 of a stratified random sample of 1000 US primary care physicians, selected from the American Medical (...) Association masterfile. Physicians were asked how much weight should be given to the following: (1) the patient’s expressed wishes and values, (2) the physician’s own judgment about what is in the patient’s best interest, (3) standards and recommendations from professional medical bodies and (4) moral guidelines from religious traditions. Results: Response rate 51% (446/879). Half of physicians (55%) gave the patient’s expressed wishes and values “the highest possible weight”. In comparative analysis, 40% gave patient wishes more weight than the other three factors, and 13% ranked patient wishes behind some other factor. Religious doctors tended to give less weight to the patient’s expressed wishes. For example, 47% of doctors with high intrinsic religious motivation gave patient wishes the “highest possible weight”, versus 67% of those with low (OR 0.5; 95% CI 0.3 to 0.8). Conclusions: Doctors believe patient wishes and values are important, but other considerations are often equally or more important. This suggests that patient autonomy does not guide physicians’ decisions as much as is often recommended in the ethics literature. (shrink)

An anthropocentric scope for clinical medical ethics (CME) has largely separated this area of bioethics from environmental concerns. In this article, we first identify and reconcile the ethical issues imposed on CME by climate change including the dispersion of related causes and effects, the transdisciplinary and transhuman nature of climate change, and the historic divorce of CME from the environment. We then establish how several moral theories undergirding modern CME, such as virtue ethics, feminist ethics, and several theories of (...) justice, promote both a flourishing of human medical practice and the environment. We conclude by defining an expanded the scope of CME as inclusive of not only patients, families, physicians, and other health professionals but other humans, non-humans, and their shared environment. We then apply this scope and theory to a widely used framework for applying CME, the Four Topics model, to construct a climate conscious approach to CME. (shrink)

Over the past decade, clinical ethics has received growing attention in Germany as in most European countries. In the mid-1990s, most European countries made efforts to establish healthcare ethics committees and clinical ethics consultation services. The development of clinical ethics discourse and activities in Germany, however, was delayed and, consequently, is still in its natal phase. Until the end of the 1990s, the only institutionalized bodies of ethical reflection were the research ethics committees at university medical centers and at (...) the State Physician Chambers. In March 1997, the Catholic and Protestant hospital association in Germany recommended the implementation of HECs, modeled after the American HECs. Consequently, the establishment of clinical ethics consultation in the form of HECs started in Germany in denominational hospitals, followed by a small but increasing number of community hospitals. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Veterans Affairs National Center for Clinical EthicsJames L. Bernat (bio)The veterans health administration is the largest health care system in the United States and, indeed, is larger that the health care system of many foreign countries. In February 1991 the Department of Veterans Affairs (V.A.) in Washington, D.C. awarded a contract to the clinical ethics group at the Veterans Affairs Medical Center in White River Junction, Vermont (...) to establish the V.A. National Center for Clinical Ethics. In this article I describe the organizational context, mission, operation, and future direction of the Center, which William A. Nelson, Ph.D., and I co-direct.The Veterans Health AdministrationThe Department of Veterans Affairs operates 171 hospitals providing services ranging from primary, secondary, and tertiary medical care to psychiatric hospitals, rehabilitation centers, and nursing homes. The V.A. also provides outpatient services at all hospitals and at dozens of free-standing outpatent clinics. V.A. medical centers employ over 14,000 physicians and serve approximately 4.5 million veteran patients (Hollingsworth and Bondy 1990; Mirvis 1990).The V.A. serves an important educational function, providing training sites for medical students, postgraduate physicians, and trainees in other health-related fields. Approximately 78 percent of V.A. medical centers are affiliated with medical schools. Over one-third of all American medical students and over 40 percent of interns and residents spend a portion of their training in V.A. medical centers. More than 100,000 students in all health-related fields train in V.A. facilities annually (Hollingsworth and Bondy 1990).Research is another mission of the V.A. Many academic physicians and scientists derive their research and salary funding from V.A contracts and awards. The V.A. Research Career Development Program provides the means for many medical school faculty members to achieve successful careers as scientists and clinical investigators. Although research accounts for only slightly more than 1 percent of the V.A. medical budget, two V.A. researchers have been awarded the Nobel Prize (Hollingsworth and Bondy 1990). [End Page 385]In comparison to other medical care settings, the average V.A. patient is likely to be older, poorer, male, less well-educated, more chronically ill, and more expensive to care for. Many patients first patronize the V.A. system after they have been bankrupted by the costs of a major illness. Unlike young, healthy patients ideally favored by health maintenance organizations, these patients immediately require large expenditures for hospitalizations, medications, and other treatments. Additional burdens have been placed on V.A. facilities by a record of chronic federal underfunding over the past decade, despite expanded patient censuses at every facility.Bioethical issues arise in V.A. facilities with great frequency for several reasons. Older and poorer patients are often sicker, have fewer home-support resources, and have completed fewer advance directives for health care. Chronic operational underfunding requires explicit health care rationing systemwide. Academic physicians within the V.A. system have multiple professional duties that have the potential for conflict. Although their primary duty is to their patients, they also must serve the federal government and their medical school academic supervisors. The practice of medical care rationing pits the physician's professional duty to his patient against his duty to the system (Mirvis 1990).The V.A. has responded to these bioethical demands with several initiatives. Hospital ethics advisory committees have been developed in nearly every V.A. medical center. The V.A. National Bioethics Committee has been empaneled to encourage uniform policies across the V.A. system concerning bioethical issues. Most recently, funds were provided for the V.A. National Center for Clinical Ethics.Functions of the National Center for Clinical Ethics (NCCE)The NCCE has a fourfold mission: 1) to enhance the quality of clinical ethics programs at all 171 V.A. medical centers nationwide; 2) to staff the V.A. National Bioethics Committee; 3) to assist administrators and planners in the V.A. Central Office on policy development concerning bioethical issues; and 4) to study, organize, and coordinate clinical, educational, and research bioethics programs throughout the system.Enhancing the quality of clinical ethics programs at V.A. medical centers is largely an... (shrink)

Innovative practice occurs when a clinician provides something new, untested, or nonstandard to a patient in the course of clinical care, rather than as part of a research study. Commentators have noted that patients engaged in innovative practice are at significant risk of suffering harm, exploitation, or autonomy violations. By creating a pathway for harmful or nonbeneficial interventions to spread within medical practice without being subjected to rigorous scientific evaluation, innovative practice poses similar risks to the wider community of (...) patients and society as a whole. Given these concerns, how should we control and oversee innovative practice, and in particular, how should we coordinate innovative practice and clinical research? In this article, I argue that an ethical approach to overseeing innovative practice must encourage the early transition to rigorous clinical research without delaying or deferring the development of beneficial innovations or violating the autonomy rights of clinicians and their patients. (shrink)

Television medical dramas frequently depict the practice of medicine and bioethical issues in a strikingly realistic but sometimes inaccurate fashion. Because these shows depict medicine so vividly and are so relevant to the career interests of medical and nursing students, they may affect these students' beliefs, attitudes, and perceptions regarding the practice of medicine and bioethical issues. We conducted a web-based survey of medical and nursing students to determine the medical drama viewing habits and impressions of (...) bioethical issues depicted in them. More than 80% of medical and nursing students watch television medical dramas. Students with more clinical experience tended to have impressions that were more negative than those of students without clinical experience. Furthermore, viewing of television medical dramas is a social event and many students discuss the bioethical issues they observe with friends and family. Television medical dramas may stimulate students to think about and discuss bioethical issues. (shrink)

This clinical ethics case examines whether to continue prescribing Adderall, an unlicensed drug in the UK, to a 30-year-old American patient with uncertain diagnosis who claims benefit from the medication. The ethics committee analyzed key tensions: balancing the patient's preference and reported benefits against diagnostic uncertainty and medical best practices, weighing short-term functioning against long-term risks of an addictive medication, and considering resource allocation implications of prescribing an unlicensed drug. While acknowledging the patient's positive response to Adderall, the (...) committee recommended trying UK-approved medications first while working to establish a clearer diagnosis and building a stronger doctor-patient relationship, rather than simply continuing to prescribe based on patient preference alone. (shrink)

*Disclaimer: The views expressed are the author's and should not be ascribed to the American Medical Association.

Travelling internationally to acquire medical treatments otherwise unavailable or inaccessible in one’s home country is not a novel concept. Conventionally, such medical travel largely entailed patients from developed countries or wealthy patients from the developing world seeking care in Western facilities like the Mayo Clinic in the U.S. and myriad private clinics along Harley Street in London, England. What is different about the topical phenomenon known as “medical tourism” is the growing trend of health services export (...) in the opposite direction. The number of patients travelling from the developed world to low- and middle-income countries for treatments has ballooned in recent years, primarily driven by difficulties with accessing affordable care at home. According to a liberal estimate by the Deloitte Center for Health Solutions, the number of Americans travelling abroad for care rose from 750,000 in 2007 to 1.6 million in 2012. On the flip side, Thailand reportedly treated a total of 1.3 million foreign nationals in 2007, which represented a 16% leap from 2001. (shrink)

Use of humanities content in American medical education has been debated for well over 60 years. While many respected scholars and medical educators have purported the value of humanities content in medical training, its inclusion remains unstandardized, and the undergraduate medical curriculum continues to be focused on scientific and technical content. Cited barriers to the integration of humanities include time and space in an already overburdened curriculum, and a lack of consensus on the exact content, (...) pedagogy and instruction. Edmund Pellegrino, physician and scholar of the latter twentieth century, spent much of his professional life promoting the value and importance of the humanities in medical education, seeking the best way to incorporate and teach this content in clinically relevant ways. His efforts included the founding of multiple enterprises starting in the 1960s and 1970s to promote human values in medical education, including the Society for Health and Human Values and its Institute on Human Values in Medicine. Regardless of his efforts and those of many others into the current century, the medical humanities remains a curricular orphan, unable to find a lasting home in medical education and training. (shrink)

Medicine is no stranger to patience. In fact, the word ‘patient’ has an etymology stemming from the Latin word ‘patiens’, describing the one who tolerates suffering.1 In this sense, the cornerstone of medicine, the patient–physician relationship, reflects passive language, ‘to suffer’. This suffering must be understood, and should be most intimately understood by those who provide care that is beyond a patient’s reach. The case of patients and their loved ones requesting medically futile care at the end of life is (...) one where further treatment is replaced by patience and, more rarely, the patience of medical teams is replaced by futile treatment. At the heart of this debate is not only the denial of futile care but also the need for understanding the extent of patience that must be endured as a result of it. Burns and Truog2 remark on this ethical dilemma: > The best solution – although perhaps also the most difficult – is…tolerating the demands for care that we believe to be futile, and finding ways to better support the emotional needs of each other in those rare cases where we are called on to provide this care. The concept of futility in care represents medical intervention with limited, or no, chance of resulting in what is regarded as a clinically successful outcome. Since the American Medical Association’s endorsement of the lack of consensus on futile care in 1999, this integral conflict remains.3 This is a conflict of understanding. I believe this understanding can be strengthened by acknowledging the Arabic word for patience, ‘ sabr ’, along …. (shrink)

Bruce Lincoln suggests that myth is "that small class of stories that possess both credibility and authority". When studying the history of mythology we find that myths often are understood as something other people have—as if the group in question possesses the truth while others live by falsehoods. In examining contemporary North American society, we can see how Judeo-Christian narratives structure popular and medical discourses regarding sex and gender. The idea that humans are born into male and female, (...) and male and female only, is a deeply held belief—so much so that it appears as fact rather than belief. Anthropologists such as Serena Nanda and Will Roscoe have documented the cross-cultural and historical "gender variants" who exist in societies where three or more genders are the norm. The origin of the belief in two sexes could well be the opening verses of Genesis where the origin of the human species is described in bipolar, dimorphic forms: "… in the image of God He created them; male and female created He them". In the article I explore the mythology that underlies the clinical management of transgender children. (shrink)

Due to its allegedly diverse population and strong doctor–patient relations, Latin America has become one of the most attractive locations for international clinical trials. In the paper, I examine the case of recruitment of women and minority patients to serve as subjects of international clinical trials, through CROs operating in Latin America. In particular, the paper examines some of the strategies that CROs use to expand their services in the Latin American medical market, illuminating the mechanisms through which (...) the current organization of medical research contributes to power imbalances in the Global South. After analyzing the epistemic and ethical shortcomings of such endeavor, I show how Latin American patients participating in clinical trials are located in a position of double disadvantage. First, they suffer the consequences of a lack of appropriate understanding of symptoms and reaction to treatment. Second, they suffer the consequences of being subjects in clinical trials which are not designed to meet their needs, but the needs of patients in the Global North. Accordingly, I conclude by highlighting the importance of this double disadvantage and suggesting that the problem can be understood in terms of a misalignment of commercial, ethical, and epistemic concerns in clinical research. (shrink)

Abstract“Clinical ethics consultants” have been practicing in the United States for about 50 years. Most of the earliest consultants—the “pioneers”—were “outsiders” when they first appeared at patients' bedsides and in the clinic. However, if they were outsiders initially, they acclimated to the clinical setting and became “insiders” very quickly. Moreover, there was some tension between traditional academics and those doing applied ethics about whether there was sufficient “critical distance” for appropriate reflection about the complex medical ethics dilemmas of (...) the day if one were involved in the decision making. Again, the pioneers deflected concerns by identifying and instituting safeguards to assure professional objectivity in clinical ethics consultation services. One might suggest that in moving inside and establishing normative practices, the pioneer clinical ethics consultants anticipated adoption of their routines and professionalization of the field. (shrink)