What is good prescribing? In this paper we will look at the kinds of criteria which are relevant to evaluating prescribing. In particular we wish to challenge, or at least re-frame, the picture of prescribing as an essentially technical process. In so doing we hope to indicate something more general about the power, and limitations, of technical rationality in health care, and to contribute something to work in health care technology assessment. Finally we hope this discussion will (...) act as a stimulus towards a much needed revision of the way ‘good’ prescribing is defined by current policies, guidelines and protocols. (shrink)

Joshua Parker’s article on green inhaler prescribing is important and timely. I agree with much of it, specifically regarding the institutional duty to make climate-friendly changes (from environmentally expensive prescriptions to ‘greener,’ similarly effective ones). The challenge, however, comes in determining how that institutional obligation impacts the rights and duties of patients. In this commentary, I want to offer a friendly alternative to Parker’s view of individual patient obligation, which I suggest is important for reasons that go beyond this (...) one case. Parker’s broad view is that, because metered-dose inhalers (MDIs) emit far more greenhouse gases (GHG) than do dry powder inhalers (DPIs), and the two are equally effective for most patients, the healthcare system should switch most patients on MDIs to DPIs, and the patients have a pro tanto duty to accept this change.1 The problem is that no individual inhaler use causes harmful climate change, and so it is difficult to explain a duty not to use MDIs. It seems that my individual behaviour ‘makes no difference’ to climate change, so familiar more principles have a difficult time justifying a prohibition of such behaviour. Parker’s response to this worry fits into the consequentialist tradition,2 3 as he argues that each individual contribution to climate change causes some amount of ‘expected harm,’ because it contributes a little bit to future climate changes which will cause harm. And since we have a duty to minimise expected harm, we have a duty not to make such small contributions to climate change. I think we should be sceptical of this sort of argument. It makes the most sense if we endorse a bathtub metaphor, in which the atmosphere is like a bathtub, and once it is full, every …. (shrink)

It is conventional wisdom among political philosophers that ideal principles of justice must guide our attempts to design institutions to avert actual injustice. Call this the ideal guidance approach. I argue that this view is misguided— ideal principles of justice are not appropriate "guiding principles" that actual institutions must aim to realize, even if only approximately. Fortunately, the conventional wisdom is also avoidable. In this paper, I develop an alternative approach to institutional design, which I call institutional failure analysis. The (...) basic intuition of this approach is that our moral assessment of institutional proposals is most effective when we proceed from a detailed understanding of the causal processes generating problematic social outcomes. Failure analysis takes the institutional primary design task to be obviating or averting institutional failures. Consequently, failure analysis enables theorists to prescribe more effective solutions to actual injustice because its focuses on understanding the injustice, rather than specifying an ideal of justice. (shrink)

In Good White People: The Problem with Middle-Class White Anti-Racism, Shannon Sullivan considers: "What can white people do to help end racial injustice?". As one response to this question, Sullivan argues that prescribing "white shame" and "white guilt" is useless, since promoting these ideas leads to self-hate and inaction on the part of white people. In this paper, I agree with Sullivan, but for different reasons. I argue that assuming that white people can feel ashamed simply about being white (...) within our current society is unfounded. I will maintain that the project of "promoting white shame" is fraught to begin with, and show the significance of this finding for conversations about white people's role in... (shrink)

Off-label prescribing is an integral part of contemporary medicine. Many patients benefit when they receive drugs or devices under circumstances not specified on the label approved by the Food and Drug Administration. An off-label use may provide the best available intervention for a patient, as well as the standard of care for a particular health problem. In oncology, pediatrics, geriatrics, obstetrics, and other practice areas, patient care could not proceed without off-label prescribing. When scientific and medical evidence justify (...) off-label uses, physicians promote patients’ interests by prescribing products off label.Off-label prescribing can also harm patients, however. The potential for harm is greatest when an offlabel use lacks a solid evidentiary basis. A 2006 study examining prescribing practices for 169 commonly prescribed drugs found high rates of off-label use with little or no scientific support. Researchers examining off-label use in U.S. children’s hospitals concluded, “[W]e still have incomplete knowledge about the safety and efficacy of many medications commonly used to treat children across a range of drug classes and clinical diagnoses.”. (shrink)

Teachers are no longer simply being told what to teach, but also how to teach it. It is important therefore to examine whether some prescriptions of teaching methods are acceptable while others are not, and to justify opposition to certain forms of prescription. I show that some attempts to prescribe teaching methods are either empty, or incompatible with holding teachers to account for the pupil learning which is supposed to result. My argument does not depend on making any value assumptions (...) about ultimate educational aims. Examples from the National Literacy and Numeracy Strategies are discussed. (shrink)

In many Western jurisdictions cannabis, unlike most other psychoactive drugs, cannot be prescribed to patients even in cases where medical professionals believe that it would ease the patient’s pain or anxiety. The reasons for this prohibition are mostly ideological, although medical and moral arguments have been formulated to support it. In this paper, it is argued that freedom, properly understood, provides a sound ethical reason to allow the use of cannabis in medicine. Scientific facts, appeals to harm and autonomy, and (...) considerations of symbolic value cannot consistently justify prohibitions. (shrink)

Sildenafil citrate (Viagra) and other newly released pharmaceuticals that assist erectile dysfunction may be one of the most important categories of drugs released in the past decade. Sildenafil is distinctive because it creates a new therapeutic relationship not only between patient and physician, but also with sexual partner(s). Physicians must first evaluate the patient comprehensively, addressing not only erectile function and sexual performance, but overall physical and mental health. Since the drug does impact others, an expanded model for informed consent (...) needs to be considered. Three models to consider include the public health one, ethically justified limits on confidentiality, and a biopsychosocial one. The biopsychosocial model may be preferred because it expands the patient-physician dyad to directly include others. Physicians also need to distinguish between professional, role-related obligations and personal conscience when treating patients whose sexual beliefs and practices differ from their own. Other ethical issues include inappropriate prescribing over the Internet, dealing with unrealistic patient expectations, and fairness in paying for treatment for sexual conditions in both men and women. With these proposed guidelines, physicians can continue to provide steady, reliable guidance for patients while working with yet another scientific advance in medicine. (shrink)

The COVID-19 pandemic has exacerbated the drug poisoning epidemic in a number of ways: individuals use alone more often, there is decreased access to harm reduction services and there has been an increase in the toxicity of the unregulated drug supply. In response to the crisis, clinicians, policy makers and people who use drugs have been seeking ways to prevent the worst harms of unregulated opioid use. One prominent idea is safe supply. One form of safe supply enlists clinicians to (...) prescribe opioids so that people have access to drugs of known composition and strength. In this paper, we assess the ethical case for clinicians providing this service. As we describe, there is much that is unknown about safe supply. However, given the seriousness of the overdose death epidemic and the current limited evidence for safe supply’s efficacy, we argue that it is ethically permissible for clinicians to begin prescribing opioids for some select patients. (shrink)

Background While it is generally acknowledged that self-prescribing among physicians poses some risk, research finds such behaviour to be common and in certain cases accepted by the medical community. Largely absent from the literature is knowledge about other activities doctors perform for their own medical care or for the informal treatment of family and friends. This study examined the variety, frequency and association of behaviours doctors report providing informally. Informal care included prescriptions, as well as any other type of (...) personal medical treatment (eg, monitoring chronic or serious conditions). Method A survey was sent to 2500 randomly-selected physicians in Colorado, 600 individuals returned questionnaires with usable data. The authors hypothesised: (1) physicians would prescribe the same types of treatment at home as they prescribed professionally; and (2) physicians who informally prescribed addictive medications would be more likely to engage in other types of informal medical care. Results Physicians who wrote prescriptions for antibiotics, psychotropics and opioids at work were more likely to prescribe these medications at home. Those prescribing addictive drugs outside of the office treated more serious illnesses in emergency situations, more chronic conditions and more major medical/surgical conditions informally than did those not routinely prescribing addictive medications. Physicians reported a variety of informal care behaviour and high frequency of informal care to family and friends. Discussion The frequency and variety of informal care reported in this study strongly argues for profession-wide discussion about ethical and guideline considerations for such behaviour. These areas are discussed in the paper. (shrink)

The National Health Service (NHS) was the first healthcare system globally to declare ambitions to become net carbon zero. To achieve this, a shift away from metered-dose inhalers which contain powerful greenhouse gases is necessary. Many patients can use dry powder inhalers which do not contain greenhouse gases and are equally effective at managing respiratory disease. This paper discusses the ethical issues that arise as the NHS attempts to mitigate climate change. Two ethical issues that pose a barrier to moving (...) away from metered-dose inhalers are considered: patients who decline an inhaler with a smaller carbon footprint and increased cost. I argue that while a patient is not morally justified in refusing a more environmentally sustainable inhaler due to the expected harms, a doctor may still prescribe a metered-dose inhaler if they believe that switching without consent might undermine trust or substantially worsen the patient’s health. Turning to cost, I argue that the imperative to combat climate change means the NHS should accept small increased financial costs for lower carbon inhalers, even though this provides no additional direct benefit for the patient. I then go on to consider the implications of the preceding analysis for policy and practice. I argue for a policy that minimises the impact of inhalers on the climate by advocating for a principle of environmental prescribing and explore decision-making in practice. While the arguments here pertain primarily to inhalers, the discussion has broader implications for debates around healthcare’s responsibility to be environmentally sustainable. (shrink)

Several recent attempts to isolate the fallacy in the view that I am committed to particular moral principles merely by describing a man as having promised seem to me to have erred through excess of zeal. The argument which commits the fallacy is at its most explicit in an article by Professor Searle, and the attempted refutations with which I am concerned fasten upon the first step in his ‘deduction’, which moves from Jones uttered the words ‘I hereby promise to (...) pay you, Smith, five dollars’ to Jones promised to pay Smith five dollars by way of the ‘fact about English usage’ which Searle states as: Under certain conditions C anyone who utters the words ‘I hereby promise to pay you, Smith, five dollars’ promises to pay Smith five dollars. (shrink)

Kihlbom has recently argued that a system of seeking negatively informed consent might be preferable in some cases to the ubiquitous informed consent model. Although this theory is perhaps not powerful enough to supplant informed consent in most settings, it lends strength to Evans’ and Hungin’s proposal that it can be ethical to prescribe placebos rather than "active" drugs. This paper presents an argument for using negatively informed consent for the specific purpose of authorising the use of placebos in clinical (...) contexts. (shrink)

Name der Zeitschrift: Kant-Studien Jahrgang: 105 Heft: 4 Seiten: 491-508.

The general aim of this work is to show the importance of the adressee's mind as planned by the author of a speech act or of a norm; in particular, how important are the expected motivations for goal adoption. We show that speech acts differ from one another for the different motivations the speaker is attempting to obtain from the hearer. The description of the participants' social positions is not sufficient. Important conflicts can arise which are not relative to what (...) to do, but to the different motives requested by the speaker. This view is applied to norms, pointing out that what is required by a norm is not only a behaviour but also a mental attitude, and that the prescribed mind might be even more important than the prescribed behaviour. Norms don't want just behavioural conformity, but also that this conformity implies an acknowledgement and a reinforcement of both the authority and the norm itself. Norms ask for submission. Any form of norm is aimed at influencing the addressee by changing his or her mind. (shrink)

Today in Japan psychoactive drugs are widely prescribed for various psychiatric disorders including so-called ‘functional’ disorders. They are undoubtedly effective in relieving various psychological and behavioral symptoms. However, Japan has yet to address some basic questions: (1) uncertainty concerning the cause of various psychiatric functional disorders; (2) unknown factors that affect the function of psychotropic drugs in patients; (3) the difficulty in obtaining objective data concerning the effects of these medications * both on the brain and the psychological symptoms (behavior); (...) and most importantly, (4) due to both the behavioral and organic (brain and CNS) effects of psychoactive drugs, the difficulty in evaluating the risk/benefit ratio between the behavioral (primary) effect and the organic (side) effect. In addition, there are bioethical problems, since these uncertainties tend to permit too broad a range of intention and too many modes of intervention in (a) prescribing and (b) taking psychoactive drugs on the part of therapists and patients, respectively. Though the increased risk of the inappropriate use of these drugs – the non-therapeutic uses, and their over-prescription – has been indicated in other industrialized countries, it has not yet been fully recognized and adequately discussed in Japan. Moreover, it is necessary to establish a sound basis for the ‘somato-psychic’ evaluation of these effects in the context of the physician-patient relationship, including the patient's family and even the broader society. Keywords: bioethics, pharmacological treatment, primary and secondary effects, psychiatric-functional disorders, risk/benefit ratio CiteULike Connotea Del.icio.us What's this? (shrink)

Kant claims that the understanding prescribes the existence and necessity of empirical laws to nature, while it does not prescribe which particular empirical laws hold. That is to say, the understanding prescribes the general form of nature and the form of the empirical laws without prescribing the material content. But how is this possible? How can the understanding guarantee that there are necessary empirical laws without prescribing particular empirical laws to nature? In this paper, I want to answer (...) this question by analyzing Kant’s argument for the Second Analogy of Experience in combination with an analysis of his conception of actuality. As I want to show, an application of Kant’s conception of actuality to the argument for the Second Analogy not only fills a gap in this argument, but also leads to an explanation of how the understanding can prescribe lawfulness to nature without prescribing particular laws. (shrink)

A distinguished political philosopher with years of experience teaching in undergraduate liberal arts programs, Anderson shows how the ideal of practical reason can reconcile academia’s research aims with public expectations for universities: the preparation of citizens, the training of professionals, the communication of a cultural inheritance. It is not good enough, he contends, to simply say that the university should stick to the great books of the classic tradition, or to denounce this tradition and declare that all important questions are (...) a matter of personal or cultural choice. By applying the methods of practical reason, instead, teachers and students will think critically about the essential purposes of any human activity and the underlying arguments of any text. (shrink)

The recent renaissance in research on psychedelic-assisted psychotherapy is showing great promise for the treatment of many psychiatric conditions. Interestingly, therapeutic outcomes for patients undergoing these treatments are predicted by the occurrence of a mystical experience—an experience characterised in part by a sense of profound meaning. This has led to hypotheses that psychedelic-assisted psychotherapy is therapeutic because it enhances perception of meaning, and consequently leads to a meaning response. The putative mechanism of action of psychedelics as meaning enhancers raises normative (...) ethical questions as to whether it can be justified to pharmacologically increase the perception of meaning in order to heal patients. Using the perspectives of hedonistic moral theories, this paper argues that if psychedelics operate as meaning enhancers, psychedelic-assisted psychotherapy can be ethically justified. An anti-hedonistic objection is presented by applying Robert Nozick’s Experience Machine thought experiment to the case of psychedelic-assisted psychotherapy. However, it is argued that this objection falls short for two reasons. First, even if pleasure and pain are not the only consequences which have moral value they are not morally irrelevant, therefore, therapeutic meaning enhancement can still be justified in cases of extreme suffering. Second, it is possible that psychedelic states of consciousness do not represent a false reality, hence their therapeutic meaning enhancement is not problematic according to Nozick’s standards. (shrink)

ABSTRACT As a classical philologist, Nietzsche was extremely familiar with the work of many ancient Greek writers. It is well known that Nietzsche made a practice of identifying with and praising ancient thinkers with whom he felt a kinship. It is worth investigating, then, whether Nietzsche's mention of Hippocrates in D signals a sustained interest in the so-called father of medicine. I argue that there is no evidence that Nietzsche paid special attention to Hippocrates or the Hippocratic corpus. Instead, Nietzsche's (...) curious allusion to Hippocrates is likely influenced in part by his reading of the Comtean positivist Émile Littré. Finally, I argue that if Nietzsche is consciously “Hippocratic” at all, he is so in virtue of the “medical posture” he adopts in D, where Nietzsche's remarks suggest his mission is to relieve humankind of the psychological suffering caused by morality. (shrink)

Using medical advances to enhance human athletic, aesthetic, and cognitive performance, rather than to treat disease, has been controversial. Little is known about physicians? experiences, views, and attitudes in this regard. We surveyed a national sample of physicians to determine how often they prescribe enhancements, their views on using medicine for enhancement, and whether they would be willing to prescribe a series of potential interventions that might be considered enhancements. We find that many physicians occasionally prescribe enhancements, but doctors hold (...) nuanced and ambiguous views of these issues. Most express concerns about the potential effects of enhancements on social equity, yet many also believe specific enhancements that are safe and effective should be available but not covered by insurance. These apparently contradictory views might reflect inherent tensions between the values of equity and liberty, which could make crafting coherent social policies on medical enhancements challenging. [Supplementary materials are available for this article. Go to the publisher's online edition of American Journal of Bioethics for the following free supplemental resource(s): An additional table (Table 5) referred to on p. 5]. (shrink)

In everyday interaction, people recurrently animate, enact, or report on talk or thought. In this article, enactments of hypothetical, non-narrative talk in advice-relevant sequences are examined, with a focus on their role in modeling desirable stance or conduct. Data consist of interactions in institutional settings, such as performance appraisal interviews, university teaching, and talk show counseling. It is demonstrated how enactments of possible talk are used as devices for hands-on demonstrations of proper or improper conduct in sequences involving orientations to (...) some kind of problematic behavior or stance, which in turn works to make assessments about different types of conduct. The accomplishment of contrasts between desired and undesired conduct is central, and contributes to the assessment of particular behaviors or stances. Different delivery formats of enactments are examined and compared to the action accomplished. It is argued that modeling talk enactments constitute resources for doing implicit criticism and ‘positive socialization’ in interaction, and that through enactments, participants may perform both explicit and implicit moral work. (shrink)

Minkoff et al. (2024) discuss the potential deprivation of medical liberties against pregnant persons following Dobbs v. Jackson Women’s Health. Another consideration is how Dobbs may impact physic...

This chapter contains sections titled: Introduction Background to the Study Actor‐Network Theory The Prescribed Curriculum: An (In)visible Token? Inferences Acknowledgments References.

In an accompanying feature article, Parker argued that general practitioners should support efforts by the National Health Service to reduce greenhouse gases by avoiding metered-dose inhalers and by prescribing similarly effective inhalers with smaller carbon footprints.1 He also argued that patients are not morally justified in declining to use dry powder inhalers which do not contain greenhouse gases and when judged to be readily available and similarly effective, unless, when patients resist that option, their trust in the professional relationship (...) is undermined.1 Prescribers should, therefore, take account of factors not only concerning the benefits and costs to individual patients including the strength of the professional relationship, but broader social considerations including potential effects on climate change and planetary health. In this commentary, I present three additional factors to broaden the context of Parker’s excellent analysis. The first is that a discussion with patients on the effects of various forms of inhalers on the environment may bring to their attention the seriousness of anthropogenic climate change and open opportunities …. (shrink)

Although the term psychotherapy evokes the idea of an incisive intervention, psychotherapy is fundamentally different from any procedure found in medicine or surgery aimed at curing a disrupted body. Psychotherapy does not aim to cure the body or even the brain; it aims to persuade a person in distress to think and behave differently. It is a method common in some form to all cultures. The late Jerome Frank, a psychiatrist and esteemed scientific investigator of psychotherapy, used the study of (...) therapies that succeeded and failed to define several characteristics common to all successful therapies (Frank and Frank 1991). In addition, he found that patients seek psychotherapy for reassurance, hope, and support .. (shrink)

In the initial wave of the opioid crisis, uninformed prescribing practices and lax oversight were the drivers of opioid addiction and death. Although opioid prescriptions have decreased by 44.4 percent between 2011-2020,1 the number of deaths linked to prescription opioids has decreased only marginally.2 The marked fall in opioid prescribing without a concomitant reduction in opioid-related deaths suggests that an at-risk population continued to receive prescription opioids, whether directly or indirectly, from a medical professional. Currently, illicitly manufactured fentanyl (...) (IMF) is the culprit for the majority of the approximately 81,000 annual opioid-related deaths.3 This finding has been misleadingly used to suggest that prescription opioids for chronic pain are no longer (and never were) a relevant concern,4 while the reality is that their lethal consequences are simply dwarfed by the marked rise in IMF deaths.5. (shrink)

The relationship between traditional and scientific ecological knowledge is a dynamic one. Consider the use of fire in land management. In the 1910s and 1920s, Aldo Leopold and other US foresters dismissively campaigned against burning as 'Paiute forestry', denigrating and driving out indigenous land management as though it had never existed, as though there was no credible ecological knowledge proir to settlement. Fire suppression as a longstanding policy across the US and Canada not only failed in reading historical tribal burning (...) practices and in applying that knowledge to settler resource management, but also systematically undercut tribal ecological knowledge. A century later, scientists and restorationists are coming to better understand the dangers of fire suppression, benefits of burns, and the fact that these are not really new insights but epistemically marginalized ones. If prescribed burning is a complex assemblage of epistemic practices, and settler-colonial reactions have perpetrated epistemic injustices against indigenous peoples, how can modern (tribal, settler, and collaborative) burning practices and policies be better? In this project, I offer a close reading of early 20th Century light-burning debates, with a particular focus on Leopold’s characterizations of indigenous ecological knowledge. I then turn to critically evaluate several 21st Century prescribed burn projects and policies for their reparative potential in both social-ecological and social-epistemic terms. (shrink)

Patient noncompliance with physician prescriptions, especially in nonsymptomatic chronic diseases, is frequently characterized in the literature as harmful and economically costly (Miller 1997).1 Nancy Houston Miller views patient noncompliance as harmful because noncompliance can result in continued or new health problems leading to hospital admissions. Further, she places the annual monetary cost of noncompliance at $100 billion.Patient noncompliance with prescribed treatment is considered the least understood form of health behavior (Coons 2001). Despite the plethora of attention in journal articles, the (...) issue of noncompliance remains unresolved even in terms of understanding the main correlates to .. (shrink)