ABSTRACT
In this paper, I examine the notion of accountability and its historical evolution in health care. Using medical mistakes and adverse patient outcomes as my focus, I examine the interests served by particular models of accountability and argue for a model of collective fiduciary responsibility in U.S. health care today.
Subject(s)
Patient Care/history , Social Responsibility , American Medical Association/history , Cost Control/history , Disclosure , History, 19th Century , History, 20th Century , Moral Obligations , Patient Care/economics , Patient Care/standards , Quality of Health Care/history , Social Change , United StatesSubject(s)
Ethics, Medical , Guidelines as Topic , Patient Selection , Pregnancy , Pregnant Women , Research Subjects , Research/standards , Eligibility Determination/standards , Federal Government , Female , Government Regulation , Humans , Informed Consent , Research Design/standards , Risk Assessment , United States , Women's HealthABSTRACT
Four case studies of successfully negotiated affiliations between Catholic and non-Catholic organizations reveal the strategies employed to address a range of reproductive health services.
PIP: This article summarizes multiple case studies on decision-making with regard to reproductive health services in affiliations between Catholic and non-Catholic organizations. A database on the number and types of affiliations was compiled during 1990-1996 to provide a national profile of such organizations. Findings of case studies revealed that affiliations between Catholic and non-Catholic health care organizations are diverse in structure, motivated by market and financial issues, and display diverse strategies with regards to reproductive health services. In addition, strategies for providing more comprehensive women's health care were evident in 3 of the 4 case studies. Availability of contraceptive services, female and male sterilization, and infertility services generally was unchanged as a result of affiliations. This shows that affiliations themselves did not significantly affect policies or practices with regards to their provision. Successful negotiations between Catholic and non-Catholic partners involve explicit strategies concerning reproductive health services, some of which curtail specific services and some of which enhance services. Finally, policy-makers have an important role in ensuring that communities receive full disclosure of the nature of affiliations and their possible impact on availability of services.
Subject(s)
Catholicism , Health Services Accessibility , Health Transition , Organizational Affiliation , Reproduction , Women's Health Services/organization & administration , Female , Humans , United StatesABSTRACT
Following up on a 1989 paper on the subject, this essay revisits the question of ethical expertise in the court room. Informed by recent developments in the use of ethics experts, the authors argue 1) that the adversarial nature of court proceedings challenges the integrity of the ethicist's pedagogical role; 2) that the use of ethics experts as normative authorities remains dubious; 3) that clarification of the State's interest in "protecting the ethical integrity of the medical profession" is urgently required; and 4) that the expertise of the ethicist may be more appropriately used in advising the legislature that in influencing the court.
Subject(s)
Ethicists , Ethics, Medical , Expert Testimony/standards , Judicial Role , Professional Role , Bioethical Issues , Cultural Diversity , Ethical Analysis , Ethics Consultation , Government , Humans , Interinstitutional Relations , Jurisprudence , Legislation, Medical , Morals , Referral and Consultation/standards , Social Values , Suicide, Assisted/legislation & jurisprudence , United States , WashingtonABSTRACT
Edmund Pellegrino has argued that the dramatic changes in American health care call for critical reflection on the traditional norms governing the therapeutic relationship. This paper offers such reflection on the obligation to "do no harm." Drawing on work by Beauchamp and Childress and Pellegrino and Thomasma, I argue that the libertarian model of medical ethics offered by Engelhardt cannot adequately sustain an obligation to "do no harm." Because the obligation to "do no harm" is not based simply on a negative duty of nonmaleficence but also on a positive duty of beneficence, I argue that it is best understood to derive from the fiduciary nature of the healing relationship.
Subject(s)
Beneficence , Cultural Diversity , Delivery of Health Care/standards , Ethics, Medical , Moral Obligations , Personal Autonomy , Physician-Patient Relations , Contract Services , Contracts , Delivery of Health Care/history , Delivery of Health Care/trends , Disclosure , Ethical Theory , Ethics, Medical/history , Freedom , Hippocratic Oath , History, 20th Century , Marketing of Health Services , Morals , Paternalism , Patient Rights , Personhood , Philosophy , Principle-Based Ethics , Risk Assessment , Secularism , Social Change , Social Responsibility , Trust , United StatesABSTRACT
In recent years the focus for the evaluation of health services has shifted from unnecessary treatment--specifically, unnecessary surgery--to appropriateness research. This new emphasis constitutes a shift in the burden of proof, indicating increased attention to the evidentiary basis of medical and surgical practice. The evaluation of the appropriateness of health services is also seen as integral to the reforming drive to contain health care costs and improve quality. Because of its pivotal role as a criterion in health care decision-making, the concept of appropriateness requires clarification. Three sources of value are defined that give meaning to "appropriateness" in patient care: the clinical point of view, the point of view of the individual patient, and the societal point of view. The framework is also used to shed light on the issue of medical futility.
Subject(s)
Health Services Misuse , Health Services/statistics & numerical data , Risk Assessment , Utilization Review/organization & administration , Attitude to Health , Consensus , Ethics, Medical , Humans , Models, Organizational , Social Values , United States , Withholding TreatmentABSTRACT
Carol Gilligan has identified two orientations to moral understanding; the dominant 'justice orientation' and the under-valued 'care orientation'. Based on her discernment of a 'voice of care', Gilligan challenges the adequacy of a deontological liberal framework for moral development and moral theory. This paper examines how the orientations of justice and care are played out in medical ethical theory. Specifically, I question whether the medical moral domain is adequately described by the norms of impartiality, universality, and equality that characterize the liberal ideal. My analysis of justice-oriented medical ethics, focuses on the libertarian theory of H.T. Engelhardt and the contractarian theory of R.M. Veatch. I suggest that in the work of E.D. Pellegrino and D.C. Thomasma we find not only a more authentic representation of medical morality but also a project that is compatible with the care orientation's emphasis on human need and responsiveness to particular others.
Subject(s)
Ethical Analysis , Ethical Theory , Ethics, Medical , Moral Development , Physician-Patient Relations , Social Justice , Adolescent , Adult , Beneficence , Child , Child, Preschool , Contracts , Female , Freedom , Humans , Infant , Male , Moral Obligations , Morals , Personal Autonomy , Personhood , Sex FactorsABSTRACT
Renal scanning is an important diagnostic aid in assessing kidney function; the authors have attempted to correlate the results of renal scanning with the findings from intravenous pyelography and the final diagnosis. In non-mass lesions of the kidney the renal scan correlated well with the intravenous pyelogram and the final diagnosis. In mass lesions, a diminished uptake of isotope corresponding to the site of the lesion seen on the intravenous pyelogram was suggestive of a cyst; diminished uptake of isotope in the whole kidney including the mass lesion on the renal scan was suggestive of renal carcinoma. Review of the literature showed only one previous reference to such an observation.
Subject(s)
Kidney Diseases/diagnosis , Kidney Neoplasms/diagnosis , Radionuclide Imaging , Adult , Aged , Evaluation Studies as Topic , Female , Humans , Kidney/abnormalities , Kidney/injuries , Kidney Diseases, Cystic/diagnosis , Male , Middle AgedABSTRACT
Spheroplasts from Saccharomyces cerevisiae NCYC 366, enriched in phosphatidylethanolamine after growth in medium supplemented with 1 mM ethanolamine, were more resistant to osmotic lysis than were spheroplasts from cells grown in the presence of 1 mM choline and enriched in phosphatidylcholine.