McCullough and colleagues draw an historical line from the writings of Percival, who found himself resolving arguments (sometimes violent) between physicians, surgeons and apothecaries, to the concept of civility as a professional virtue and duty. The authors show that civility is a prerequisite to effective cooperation, which itself underpins patient safety and positive clinical outcomes—desirable endpoints of any discussion about healthcare. They exhort academic leaders to teach, role model and reward correct behaviours.1 Why then, as a clinician manager with a (...) deep interest in fostering civility and psychological safety, am I not satisfied? Three reasons: the paper does not adequately explore the reasons why, its focus is largely restricted to academic institutions, and it does not encompass the non-clinical workforce; as a result, its proposed solutions appear ungrounded. Why are ‘good people’, who were attracted to careers that demand altruism and empathy, uncivil in the workplace? What are the competing goals that result in curt, disrespectful or downright rude exchanges? This has been studied. Leape et al concluded that endogenous factors such as personality, insecurity, anxiety, depression, narcissism and responses to prior …. (shrink)

By illuminating the striking affinity between the most innovative aspects of postmodern thought and religious mystical discourse, Shadow of Spirit challenges the long established assumption that western thought is committed to nihilism. This collection of essays by internationally recognized scholars explores the implications of the fascination with the "sacred," "divine" or "infinite" which characterizes much contemporary thought. It shows how these concerns have surfaced in the work of Derrida, Baudrillard, Lyotard, Kristeva, Irigaray and others. Examining the connection between this postmodern (...) "turn" and the current search for a new discourse of ethics and politics, it also stresses the contribution made by feminist thought to this unexpected intellectual direction. (shrink)

Patient autonomy and distributive justice are fundamental ethical principles that may be at risk in liver transplant units where decisions are dictated by the need to maximise the utility of scarce donor organs. The processes of patient selection, organ allocation and prioritisation on the wait list have evolved in a constrained environment, leading to high levels of complexity and low transparency. Regarding paternalism, opaque listing and allocation criteria, patient factors such as passivity, guilt, chronic illness and sub-clinical encephalopathy are cited (...) as factors that may inhibit patient engagement. Regarding justice, established regional, gender and race based inequities are described. The paradox whereby hepatologists both advocate for individual patients and discharge their duty of stewardship to apportion organs according to larger utilitarian principles is explored. Competing subjective factors such as physicians’ perception of moral responsibility, the qualitative nature of expert medical assessment and institutional or personal loyalty to re-transplantation candidates are described. Realistic limits of self-determination and justice are discussed, and possible future directions in terms of patient involvement proposed. (shrink)

Philip Berry examines the case of euthanasia from very close emotional range.

Assisted dying (AD) has not been legalized despite a number of presentations to parliament. It is necessary for doctors who support AD to justify themselves in the context of repeated legislative failure. This article describes the author's personal approach to the problem, one that prioritizes respect for autonomy above legal or societal objections. It is argued that for debilitated patients, the preservation of autonomy depends on a doctor's empathy and willingness to advocate. This sequence can be interrupted by externally and (...) internally imposed barriers. External factors include indiscriminate respect for the law and society's institutions, an inaccurate perception of the balance of risks to society and insufficient compensation for the dying person's inability to mount a sustained challenge. Internal brakes to advocacy such as elevation of personal morality above the needs of patients, attenuation of the therapeutic relationship in cases of moral complexity and the temptation to abdicate the role of physician are also explored. It is concluded that if AD could in theory be of benefit to a patient, but cannot be achieved due to its illegality, doctors have a duty to actively represent their demands as they would for other forms of treatment. (shrink)

Cardiopulmonary resuscitation is frequently performed on patients who, in retrospect, had a very low chance of survival. This is because all patients are ‘For cardiopulmonary resuscitation’ on admission to hospital by default, and delays occur before cardiopulmonary resuscitation can be ‘de-prescribed’. This article reviews the nature of potential harms caused by futile cardiopulmonary resuscitation, the reasons why de-prescription may be delayed, recent legal judgements relevant to timely do not attempt cardiopulmonary resuscitation decision making, and the possible detrimental effects of do (...) not attempt cardiopulmonary resuscitation discussions on end of life care. The moral and operational feasibility of a model in which informed consent must be obtained before cardiopulmonary resuscitation is attempted in some patient groups is then explored. (shrink)

Recognising a diminution in his emotional response to patients’ deaths, the author analyses in detail his internal reactions in an attempt to understand what he believes is a common phenomenon among doctors. He identifies factors that may erode the connection between patient and physician: an instinct to separate oneself from another’s suffering, professional unease in the case of therapeutic failure, the atrophying effect of perceived hopelessness, insincerities in the establishment of the initial relationship, and an inability to imbue the sedated (...) or unconscious patient with human qualities. He concludes that recognition of these negative influences, without necessarily changing behaviours that are natural, may be a first step towards protecting doctors against what might be an otherwise insidious process of dehumanisation. (shrink)

The motives behind the author’s decision to resuscitate a patient are examined. This is prompted by the realisation that he ignored the man’s apparent wish not to be saved for fear of criticism from both relatives and colleagues. The way in which decisions are made when the interests of the doctor and the patient clash are briefly explored. Self interest may play a more significant role than is commonly accepted.

A terminally ill man requests that his life be brought to a peaceful end by the doctor overseeing his care. The doctor, an atheist, regretfully declines. The patient, unsatisfied by the answer and increasingly desperate for relief, presses the doctor for an explanation. During the ensuing dialogue the philosophical, ethical and emotional arguments brought to bear by both the doctor and the patient are dissected.

In cases of sudden, life-threatening illness where the chance of survival appears negligible to the admitting physician, this opinion is not always revealed during the initial meeting with the patient's relatives. Reasons as to why this withholding of the truth may be acceptable are explored through review of available evidence and personal reflection. Factors identified include: the importance of hope in families' coping mechanisms, and the instinct to preserve it; the fallibility of physicians' perception of poor prognosis in the early (...) phase of illness; the need to avoid large swings in relatives' expectations that occur when patients appear to rally during initial resuscitation; and the adverse effect that an atmosphere of hopelessness can have on the provision of medical care. A strategy for the staged disclosure of information and the confirmation of hopelessness is then described, the aim being to find a compromise between providing a true opinion about a patient's prognosis, and regard for the opposing factors described. (shrink)