This chapter contains sections titled: Notes.

Where a decision has been made to stop futile treatment of critically ill patients on an intensive care unit – what is termed withdrawal of treatment in the UK – yet no doctor is available to perform the actions of withdrawal, nurses may be called upon to perform key tasks. In this paper I present two moral justifications for this activity by offering answers to two major questions. One is to ask if it can be in patients' best interests (...) for nurses to be the key actors in withdrawal of life‐sustaining treatment. The other is to ask if there is any reason that the nursing profession should not undertake such tasks if this is so. Both these questions require the resolution of weighty moral and philosophical issues. Thus, while offering a serious attempt to provide moral justifications for nurses undertaking withdrawal, this paper also invites debate over both the aim of task division between nurses and doctors, and how we might decide what is in the best interests of patients. (shrink)

The good Doctor has a lot to say about philosophy.

As the Covid-19 pandemic struck, many healthcare providers switched to telemedicine to deliver medical care through computer and phone screens. How can historians make sense of this use of technolo...

This is the first in-depth philosophical investigation of Doctor Who in popular culture.

On October 14, 2003, the Supreme Court announced that it would not review a Ninth Circuit Appeals Court ruling that enjoined the federal government from punishing doctors who recommend medical use of marijuana to their patients. The Ninth Circuit case, Conan v.Walters, drew a fine line in distinguishing betweendispensing information and dispensing controlled substances, and held that [p]hysicians must be able to speak frankly and openly to patients under the First Amendments. Although unauthorized use and distribution of marijuana is prohibited, (...) the court found that a doctor s recommendation does not itself constitute illegal conduct that doctors should be free to recommend the use of medical marijuana if based on sincere medical judgment, without fear of retaliation by a government probe or prosecution. (shrink)

Originally premiering in 1963, the BBC television series Doctor Who has long been criticized for essentializing colonial scenarios and failing to address issues of race and post-colonial realities. As a white male with the privilege to explore time and space, the titular Doctor stands in contrast to his human companion Martha Jones, a Black woman who represents the first and only main character in the show to be a medical professional of color. The relationship between the Doctor (...) and Martha inherently demands an exploration of the meaning of doctorhood. In studying the ways in which these characters embody the idea of “doctor,” we examine how race structures their approach to medicine, heroism, and colonialism. Whereas the Doctor personifies the figure of colonizer and post-colonial white savior, Martha emerges as a radical figure whose doctorhood potentially challenges and dismantles the colonial history of medicine. Through Afrofuturist and Afrosurrealist lenses, Martha represents a potentially subversive figure who offers a visionary medicine rooted in social justice. (shrink)

When doctors become aware of a threat to public health, they have a professional duty to try to mitigate the threat. Climate change is a recognized major threat to planetary and public health that...

La série Doctor Who est parvenue, en cinquante ans d’existence, à mettre en place une mythologie dans laquelle technologie et mythes des origines ont donné vie à un univers que la majorité des personnages perçoit comme étant « magique ». Tout comme le magicien ou la figure du sage dans le monomythe campbellien, le Docteur apparaît toujours au bon moment et provoque l’appel de l’aventure qui guide ses compagnons humains dans un monde merveilleux. Offrant souvent des explications pseudo-scientifiques incompréhensibles (...) pour le commun des mortels, le Docteur ressemble ainsi au magicien d’Oz dont les pouvoirs magiques viennent d’une maîtrise scientifique supérieure à celle de ses interlocuteurs. Mais la représentation de ce magicien spatio-temporel a pris une toute nouvelle tournure lorsqu’il est devenu évident que le Docteur et Merlin avaient une histoire et des origines communes. In fifty years, Doctor Who managed to develop a mythology in which technology and origin myths gave birth to a universe that most characters perceive as “magical”. Just like the wizard or the wise in the Campbellian monomyth, the Doctor systematically appears at the right moment and provokes the call to adventure that will lead his human companions in a wonderful world. His pseudo-scientific explanations, often incomprehensible for us mortals, thus create a certain connection between the Doctor and the Wizard of Oz, whose magic powers result from a superior knowledge of science. But the representation of this spatiotemporal magician became quite different when the Doctor and Merlin started to have a common history and a same origin. (shrink)

This article is about time. It is about time, or more precisely, about the absence of time in law’s digital future. It is also about time travelling and the seemingly ever-popular BBC science fiction television series Doctor Who. Further, it is about law’s timefullness; about law’s pictorial past and the ‘visual baroque’ of its chronological fused future. Ultimately, it is about a time paradox of seeing time run to a time when time runs ‘No More!’ This ‘timey-wimey’ article is (...) in three parts. The first part looks to a hazy remembered past of the legal emblem tradition as presented in Peter Goodrich’s Legal Emblems and the Art of Law to learn visual literacy and also to glimpse the essential elements of modern legality with authority, decision and violence. The second part maps how these images and icons of modern legality are manifest in the Doctor Who fiftieth year anniversary special ‘The Day of the Doctor.’ The third stage looks beyond these first order meanings to understand the chronological chaos of ‘The Day of the Doctor.’ The technicity of the image as a portal through time and space that the narrative revolves around charts the implications for the digital end of time for law. (shrink)

We report here an emerging dispute in Italy concerning triage criteria for critically ill covid-19 patients, and how best to support doctors having to make difficult decisions in a context of insufficient life saving resources. The dispute we present is particularly significant as it juxtaposes two opposite views of who should make triage decisions, and how doctors should best be supported. There are both empirical and normative questions at stake here. The empirical questions pertain to the available level of evidence (...) that healthcare professionals would rather not be left alone with their ‘clinical judgments’ to make triage decisions, and to the accounts of distributive justice that doctors and healthcare professionals rely on, when making triage decisions. The normative questions pertain to how this empirical evidence should inform guidelines on how prioritisation decisions are made in a context of emergency, and who gets to have the authority to do so. This debate goes beyond the discussion of the care of critically ill patients with COVID-19 and has broader implications beyond the national context for the discussion of how to relieve moral distress in contexts of imbalances between healthcare resources and clinical needs of a population. (shrink)

Organ trafficking is officially banned in several countries and by the main Nephrology Societies. However, this practice is widespread and is allowed or tolerated in many countries, hence, in the absence of a universal law, the caregiver may be asked for advice, placing him/her in a difficult balance between legal aspects, moral principles and ethical judgments.In spite of the Istanbul declaration, which is a widely shared position statement against organ trafficking, the controversy on mercenary organ donation is still open and (...) some experts argue against taking a negative stance. In the absence of clear evidence showing the clinical disadvantages of mercenary transplantation compared to chronic dialysis, self-determination of the patient may conflict with other ethical principles, first of all non-maleficence. The present paper was drawn up with the participation of the students, as part of the ethics course at our medical school. It discusses the situation in which the physician acts as a counselor for the patient in the way of a sort of “reverse” informed consent, in which the patient asks advice regarding a complex personal decision, and includes a peculiar application of the four principles to the donor and recipient parties. (shrink)

During the 20th Century, thirty-two state legislatures passed laws that sanctioned coercive sexual sterilization as a solution to the purported detrimental increases in the population of “unfit” or “defective” citizens. While both scholarly and popular commentary has attempted to attribute these laws to political parties, or to broad or poorly defined ideological groups such as “progressives,” no one has identified the political allegiance of each legislator who introduced a successfully adopted sterilization law, and the governor who signed it. This article (...) remedies that omission. (shrink)

This study explores the amount of control patients have versus the amount of control physicians have in making decisions regarding what course will be taken in the face of disease. This includes decisions about aggressive treatment, alternatives to aggressive treatment, hospice care, and possibly physician‐assisted death, if that is an option. The findings of this research conclude that there are many levels of control for physicians and patients, and that in certain cases patients may have limited control and in other (...) circumstances patients are entirely in control over their healthcare decisions. The personalities and education levels of both the physicians and the patients determine what kinds of options and control a patient will have. (shrink)

Objective Futile treatment, which by definition cannot benefit a patient, is undesirable. This research investigated why doctors believe that treatment that they consider to be futile is sometimes provided at the end of a patient9s life. Design Semistructured in-depth interviews. Setting Three large tertiary public hospitals in Brisbane, Australia. Participants 96 doctors from emergency, intensive care, palliative care, oncology, renal medicine, internal medicine, respiratory medicine, surgery, cardiology, geriatric medicine and medical administration departments. Participants were recruited using purposive maximum variation sampling. (...) Results Doctors attributed the provision of futile treatment to a wide range of inter-related factors. One was the characteristics of treating doctors, including their orientation towards curative treatment, discomfort or inexperience with death and dying, concerns about legal risk and poor communication skills. Second, the attributes of the patient and family, including their requests or demands for further treatment, prognostic uncertainty and lack of information about patient wishes. Third, there were hospital factors including a high degree of specialisation, the availability of routine tests and interventions, and organisational barriers to diverting a patient from a curative to a palliative pathway. Doctors nominated family or patient request and doctors being locked into a curative role as the _main_ reasons for futile care. Conclusions Doctors believe that a range of factors contribute to the provision of futile treatment. A combination of strategies is necessary to reduce futile treatment, including better training for doctors who treat patients at the end of life, educating the community about the limits of medicine and the need to plan for death and dying, and structural reform at the hospital level. (shrink)

There is a growing belief in the US that medicine is an altruistic profession, and that physicians display altruism in their daily work. We argue that one of the most fundamental features of medical professionalism is a fiduciary responsibility to patients, which implies a duty or obligation to act in patients' best medical interests. The term that best captures this sense of obligation is “beneficence”, which contrasts with “altruism” because the latter act is supererogatory and is beyond obligation. On the (...) other hand, we offer several examples in which patients act altruistically. If it is patients and not the doctors who are altruistic, then the patients are the gift-bearers and to that extent doctors owe them gratitude and respect for their many contributions to medicine. Recognising this might help us better understand the moral significance of the doctor-patient relationship in modern medicine. (shrink)

Who should decide? In When Doctors Say No, philosopher and bioethicist Rubin examines this controversial issue.

Context The attitudes of medical professionals towards physician assisted dying have been widely discussed. Less explored is the level of agreement among physicians on the possibility of ‘rational suicide’—a considered suicide act made by a sound mind and a precondition of assisted dying legislation. Objective To assess attitudes towards rational suicide in a representative sample of senior doctors in England and Wales. Methods A postal survey was conducted of 1000 consultants and general practitioners randomly selected from a commercially available database. (...) The main outcome of interest was level of agreement with a statement about rational suicide. Results The corrected participation rate was 50%; 363 questionnaires were analysed. Overall 72% of doctors agreed with the possibility of rational suicide, 17% disagreed, and 11% were neutral. Doctors who identified themselves as being more religious were more likely to disagree. Some doctors who disagreed with legalisation of physician assisted suicide nevertheless agreed with the concept of rational suicide. Conclusions Most senior doctors in England and Wales feel that rational suicide is possible. There was no association with specialty. Strong religious belief was associated with disagreement, although levels of agreement were still high in people reporting the strongest religious belief. Most doctors who were opposed to physician assisted suicide believed that rational suicide was possible, suggesting that some medical opposition is best explained by other factors such as concerns of assessment and protection of vulnerable patients. (shrink)

Background: Ethics consultation is used regularly by some doctors, whereas others are reluctant to use these services.Aim: To determine factors that may influence doctors to request or not request ethics consultation.Methods: A survey questionnaire was distributed to doctors on staff at the University Community Hospital in Tampa, Florida, USA. The responses to the questions on the survey were arranged in a Likert Scale, from strongly disagree, somewhat disagree, neither agree nor disagree, somewhat agree to strongly agree. Data were analysed with (...) the Wilcoxon test for group comparisons, the χ2 test to compare proportions and a logistic regression analysis.Results: Of the 186 surveys distributed, 121 were returned, giving a 65% response rate. Demographic data were similar between the groups saying yes and no . No statistically significant differences were observed between the user and non-user groups in terms of opinions about ethics consultants having extensive training in ethics or participating in ethics educational opportunities. On the issue “Ethics committee members or consultants cannot grasp the full picture from the outside”, the non-users were neutral, whereas the users somewhat disagreed . Even more significant was the difference between surgeons and non-surgeons, where, by logistic regression analysis, surgeons who believed that ethics consultants could not grasp the full picture from the outside were highly likely to not use . Non-users of ethics consultations thought that it was their responsibility to resolve issues with the patient or family . Users of ethics consultation believed in shared decision making or the importance of alternate points of view .Implications: Ethics consultations are used by doctors who believe in shared decision making. Doctors who did not use ethics consultation tended to think that it was their responsibility to resolve issues with patients and families and that they were already proficient in ethics. (shrink)

Athletes who wish to compete in spite of high risk of injury can prove a challenge for sports doctors. Overriding an athlete's choices could be considered to be unnecessarily overbearing or paternalistic. However simply accepting all risk-taking as the voluntary choice of an individual fails to acknowledge the context of high-level sport and the circumstances in which an athlete may be being coerced or in some other way be making a less than voluntary choice. Restricting the voluntary choices of an (...) athlete may still be possible but under very limited circumstances. This article explores the ways a sports doctor might respond in ensuring a choice is indeed voluntary and, if so, under what circumstances limits might be placed. Responding to such risk-taking by, for example, limiting the actions of an athlete or assisting them to compete, involves attempting to balance the athlete's aims against some set of ideals of good health or medical ends. (shrink)

A collection of dramatic accounts about doctors who have faced the moral dilemma of choosing between obeying rules and doing what is best for a patient offers insight into the essential principles of medical ethics and their impact on ...

A hypothetical scenario is presented in which a female patient is admitted to a private hospital to undergo a mastectomy and breast reconstruction. The surgeons and anaesthetists conducting the different procedures charge three times the medical aid rates. When the patient asks what the co-payments are likely to be, she is informed by the doctors’ accounts section that they can only provide this information after each procedure. The patient’s medical scheme also advises her that it cannot determine the likely co-payments (...) unless she completes the assessment form sent to her. The form requires her to include the costs reflected against the relevant ICD10 codes. The patient cannot complete the form because the doctors’ accounts sections have not informed her about the proposed procedures and the likely costs of each. This article builds on a previous article discussing doctors’ overarching responsibility to disclose medical treatment costs in advance. The present article outlines the legal requirements in the South African Constitution, the National Health Act and the Health Professions Act, and refers to the Promotion of Access to Information Act and Consumer Protection Act. Similar to the earlier article, this article addresses the ethical requirements of the Health Professions Council of South Africa and the internationally recognised biomedical ethical principles. Furthermore, it also refers to the National Patients Charter, the government’s policy document on health care services. (shrink)

Background and Aims The prevalence of religious faith among doctors and its relationship with decision-making in end-of-life care is not well documented. The impact of ethnic differences on this is also poorly understood. This study compares ethnicity and religious faith in the medical and general UK populations, and reports on their associations with ethically controversial decisions taken when providing care to dying patients. Method A postal survey of 3733 UK medical practitioners, of whom 2923 reported on the care of their (...) last patient who died. Findings Specialists in care of the elderly were somewhat more likely to be Hindu or Muslim than other doctors; palliative care specialists were somewhat more likely to be Christian, religious and ‘white’ than others. Ethnicity was largely unrelated to rates of reporting ethically controversial decisions. Independently of speciality, doctors who described themselves as non-religious were more likely than others to report having given continuous deep sedation until death, having taken decisions they expected or partly intended to end life, and to have discussed these decisions with patients judged to have the capacity to participate in discussions. Speciality was independently related to wide variations in the reporting of decisions taken with some intent to end life, with doctors in ‘other hospital’ specialities being almost 10 times as likely to report this when compared with palliative medicine specialists, regardless of religious faith. Conclusions Greater acknowledgement of the relationship of doctors' values with clinical decision-making is advocated. (shrink)

BackgroundAssisted dying has wide support among the general population but there is evidence that those providing care for the dying may be less supportive. Senior doctors would be involved in implementing the proposed change in the law. We aimed to measure support for legalising physician assisted dying in a representative sample of senior doctors in England and Wales, and to assess any association between doctors' characteristics and level of support for a change in the law.MethodsWe conducted a postal survey of (...) 1000 consultants and general practitioners randomly selected from a commercially available database. The main outcome of interest was level of agreement with any change in the law to allow physician assisted suicide.ResultsThe corrected participation rate was 50%. We analysed 372 questionnaires. Respondents' views were divided: 39% were in favour of a change to the law to allow assisted suicide, 49% opposed a change and 12% neither agreed nor disagreed. Doctors who reported caring for the dying were less likely to support a change in the law. Religious belief was also associated with opposition. Gender, specialty and years in post had no significant effect.ConclusionMore senior doctors in England and Wales oppose any step towards the legalisation of assisted dying than support this. Doctors who care for the dying were more opposed. This has implications for the ease of implementation of recently proposed legislation. (shrink)

The physician’s duty of confidentiality is based on the observance of the patient’s privacy and intimacy and on the importance of respecting both of these rights, thus creating a relationship of confidence and collaboration between doctor and patient. The main objective of this work consists of analyzing the aspects that are related to the confidentiality of patients’ data with respect to the training, conduct and opinions of doctors from different Clinical Management Units of a third-level hospital via a questionnaire. (...) The present study aimed to define the problem and determine whether the opinions of these professionals correspond to those observed in a previous work conducted at the same center. Of the 200 questionnaires that were collected, 62.5% were from consultants and the rest were from residents with an average of 14.4 ± 12.5 years in professional practice. The respondents noted habitual situations in which confidentiality was breached in the reference hospital. The section on their attitudes and behaviors towards situations related to confidentiality showed a slightly lower average score than that of their medical knowledge; significant differences in these scores were observed between the consultants and residents as well as between the extreme age groups and years of professional practice, thus more inadequate attitudes were consistently noted in younger doctors who had fewer years of experience. Finally, the respondents answered that the training of doctors in the aspects of healthcare law and ethics was the most important measure that the hospital could adopt regarding confidentiality practices. (shrink)

Since at least the Karen Ann Quinlan case, the idea of autonomy has always been central to the discussion about whether to given life-prolonging treatment. Those on different sides of the debate may disagree strongly about some of the issues, but the importance of the patient's autonomy has been accepted by people of widely different points of view.

In an article in this journal, Christopher Cowley argues that we have ‘misunderstood the special nature of medicine, and have misunderstood the motivations of the conscientious objectors’. We have not. It is Cowley who has misunderstood the role of personal values in the profession of medicine. We argue that there should be better protections for patients from doctors' personal values and there should be more severe restrictions on the right to conscientious objection, particularly in relation to assisted dying. We argue (...) that eligible patients could be guaranteed access to medical services that are subject to conscientious objections by: removing a right to conscientious objection; selecting candidates into relevant medical specialities or general practice who do not have objections; demonopolizing the provision of these services away from the medical profession. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Holding Doctors Responsible at Guantánamo*Nancy Sherman (bio)I recently visited the Guantánamo Bay Detention Center with a small group of civilian psychiatrists, psychologists, top military doctors, and Department of Defense health affairs officials to discuss detainee medical and mental health care. The unspoken reason for the invitation to go on this unusual day trip was the bruising criticism the Bush administration has received for its use of psychiatrists and psychologists (...) in the interrogation of suspected terrorist detainees.1We disembarked from our Navy jet to find an island lush and green from recent storms. A small boat took us from the airfield to the naval hospital. From the boat there was no sign of Camp Delta, where the detainees are actually held. Nor was there a sign of prisons or barbed wire or the detention facility's 505 inmates.Our host was the commanding officer of Gitmo, Major General Jay W. Hood (an artillery officer by training), who had replaced Major General Geoffrey Miller, implicated in the "migration" of torture methods from Gitmo to Abu Ghraib. Dressed in fatigues, General Hood briefed us using PowerPoint. His intelligence director told us that interrogators have not used harsh "fear up" tactics—the ones designed to terrify—since 2003.We went by bus from the naval hospital to the 30-bed detainee hospital for quick briefings from a psychiatrist and a physician. Still, we were not permitted to see any detainees or hunger strikers, despite our requests. During our six hours on the ground, we had only a fleeting glimpse of a few detainees outside their cellblocks behind barbed wire and screened fences.Indeed, when I got home and saw the play "Guantánamo: Honor Bound to Defend Freedom," by Victoria Brittain and Gillian Slovo, I had the disquieting feeling that I had absorbed more about detainee life at the theater than I had from actually being at Gitmo. This only amplified my anxiety that what I had heard and seen during my VIP visit sidestepped the central moral issue of whether abuse is still occurring at Gitmo and whether health professionals are, or have been, a party to coercive interrogation. [End Page 199]The question that the Pentagon leadership has been focusing on, and which was a key subject of discussion during our day at Gitmo, is whether there is an ethical difference between using psychologists or psychiatrists on interrogation teams—what the Pentagon calls, "behavioral consultation teams," or BSCTs, pronounced "biscuit." Some in the Pentagon would like to have doctors and psychiatrists, who are bound by the Hippocratic teaching to "do no harm," be the clinicians treating detainees. Psychologists, who are not as bound by Hippocratic dicta, would consult with and advise interrogators. But this is a red herring. It is hair-splitting that detracts from the real issue of whether health professionals of any stripe can ethically be involved in interrogations that may involve coercive techniques or torture. The answer is clearly no. They should not be involved, directly or indirectly, in situations that may lead to the breach of confidential medical records; to torture or to cruel, inhumane, and degrading treatment; or to exploitation of fears or phobias. Mental health professionals simply should not be collaborating with interrogators in inflicting psychological torture.Hood said that "rapport building" was the preferred and an effective interrogation technique, but that is no guarantee that rougher tactics will not be used. The fact is that there is enormous pressure on the people at Guantánamo Bay to get good intelligence for the war on terror, and it is as easy for behavioral scientists as it is for interrogators to compromise their moral standards. Cunning and deception to extract information may be acceptable in some cases. But many people have been outraged to learn from media reports that methods developed by military psychologists to train our own troops to resist torture—the so-called "survival, evasion, resistance, and escape" methods taught at Ft. Bragg—have been "reverse engineered" at Guantánamo Bay to create coercive, psychologically manipulative interrogation techniques for use against detainees.Plato warned long ago that a doctor's skill, abstracted from good character and wisdom, is a neutral... (shrink)

"--Daniel Callahan, cofounder of the Hastings Center "Doctors and people who have no choice but to trust doctors--which means all of us--need to read this book.

Saggar recalled a patient who … asked, “Doctor, do you really think I have COVID?” At that point, Saggar wasn’t sure. He told him they were being “extra cautious.” About 10 days later, the patient was dead. “That still haunts me,” Saggar said.Infectious disease specialist Dr. Suraj Saggar says he is “haunted”. We cannot tell precisely what haunts him: the death of his patient, or his in-ability, 10 days earlier, to say for certain whether the patient was infected with (...) the new coronavirus. Probably the two merge, so that for him the sadness and horror we all feel when a person we know suddenly dies is inseparable from the particular guilty grief he feels as a doctor, not simply for being unable to save a... (shrink)

In contemporary paternalism literature, persuasion is commonly not considered paternalistic. Moreover, paternalism is typically understood to be problematic either because it is seen as coercive, or because of the insult of the paternalist considering herself superior. In this paper, I argue that doctors who persuade patients act paternalistically. Specifically, I argue that trying to persuade a patient (here understood as aiming for the patient to consent to a certain treatment, although he prefers not to) should be differentiated from trying to (...) convince him (here understood as aiming for the patient to want the treatment) and recommending (the doctor merely providing her professional opinion). These three forms of influence are illustrated by summaries of video-recorded hospital encounters. While convincing and recommending are generally not paternalistic, I argue that persuasion is what I call communicative paternalism and that it is problematic for two reasons. First, the patient’s preferences are dismissed as unimportant. Second, the patient might wind up undergoing treatment against his preferences. This does not mean that persuasion always should be avoided, but it should not be undertaken lightly, and doctors should be aware of the fine line between non-paternalism and paternalism. The fact that my analysis of paternalism differs from traditional accounts does not imply that I deem these to be wrong, but rather that paternalism should be considered as a more multi-faceted concept than previous accounts allow for. (shrink)

As Sorcerer Supreme, Doctor Stephen Strange has had several occasions in which he had to deal with the concept of a personal God. Despite his lack of traditional faith, there are important instances in which Doctor Strange acknowledges the Creator God using expressions drawn from the Western monotheistic traditions. In his Metaphysics, the ancient Greek philosopher Aristotle presents the idea of God, or more specifically a god among the gods, who is responsible for the origin and operation of (...) the whole universe. A more helpful image of God can be found in the writing of Saint Thomas Aquinas, who formed a theological synthesis of Aristotelian philosophy and Christian revelation. According to Aquinas, the all‐good Creator of the universe is the author of the moral law. In the Chronicles of Narnia, author and English professor C. S. Lewis refers to the eternal law of God as the “deep magic” that comes from the “Emperor Beyond the Sea”. (shrink)

Medical doctors are commissioned by the migration authorities and/or border police to assist in decision making about asylum seeker’s requests for residency permits in Sweden. They are asked to: (i) assess the formal written medical opinions made by physicians in support of asylum or humanitarian narratives in the asylum process and/or (ii) to make medical assessments of persons considered for deportation. This arrangement raises questions such as: How is the decision making process carried out? How is medical knowledge used, and (...) who ought to make decisions about medical evidence in the asylum process? Does this approach effect public health overall? There are longstanding concerns that medical assessments to certify whether a person is fit for transport or not, can have a direct, negative impact on persons in need of care and protection. A separate structure of doctors commissioned by the immigration authority seems to raise professional tensions, politicizes medical constructs and contributes to moral disengagement. Empirical data are used to illustrate this discussion with reference to medical issues, medical ethics, public health and legal discourses. I then reflect on key value conflicts using public health ethics theory and conclude with implications for public health ethic theory, policy and practice. (shrink)

Inadequate diet is the leading risk factor for morbidity and mortality worldwide. However, approaches to identifying inadequate diets in clinical practice remain inconsistent, and dietary interventions frequently focus on facilitating ‘healthy choices’, with limited emphasis on structural constraints. We examine the ethical implications of introducing a routine question in the medical history about ability to access food. Not collecting data on food security means that clinicians are unable to identify people who may benefit from support on an individual level, unable (...) to consider relevant dietary risk factors for disease and disease progression and unable to monitor population trends and inequalities in dietary access in order to design effective policy interventions. We argue that the current lack of routine screening for food insecurity is inconsistent with our approach to other health behaviours, as well as with doctors’ frequent informal role as gatekeepers to the food aid system, and recent calls for governmental action on food insecurity and health inequalities from individual clinicians and professional bodies. Potential ethical barriers to asking patients about food security are addressed, including concerns about stigma, limiting autonomy, fair resource allocation, unclear professional remits and clinicians’ ability to offer effective interventions. We suggest that there is an ethical imperative for doctors to ask patients about their ability to access healthy food. Gathering this data provides a valuable first step in re-framing the social determinants of health as modifiable risks, rather than inevitable inequities. No data are available. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:When Doctors Get It WrongKonrad BlairThe BeginningIt was a gloomy winter day as I sat in the back of the car while my father and mother drove me to another appointment in Pittsburgh. It was and wasn’t like so many car trips of my childhood for so many doctors’ appointments. The same deadening silence filled [End Page 89] the car as we drew closer to our destination. My parents (...) never discussed the appointments with me and I just learned to never ask. This appointment was different though; it came about as a result of request by a psychology professor who was conducting a follow–up study on individuals treated by the team of endocrinologists I saw as a child.The professor had reached out to me through my parents, since that was the only contact information available. It had been more than ten years since I had seen any of the doctors who treated me as a child. I was living in another state when I received the call from my mother informing me of the request for my participation in the study. I was really quite shocked; in all the years I was treated in early childhood and adolescence, no one had ever asked me how I felt about the treatment I received. I knew I had a medical condition, but no one ever explained to me why I needed so many appointments, and why I had to take medicine three times a day. No one told me why, when I was two or three years old, I had surgery that left me with memories of gauze and a catheter between my legs, or why medical residents still wanted to examine me, or why I had to be humiliated and ashamed, again and again. I was in my early 30’s by this time. Surely if my condition was so important that someone wanted to talk to me now, so many years later, the conversation would have already happened?!My parents dropped me off at the scheduled location for the interview. The professor introduced himself and his colleague. I didn’t recognize them, which meant they weren’t the doctors who had treated me. I remember feeling somewhat relieved, as I never liked the doctors who treated me as a child. I remembered my last appointment there, and feeling that I was escaping from captivity, that I was free to go on with my life.I wasn’t sure what to expect from this meeting. The professor told me that to date no one had completed any follow–up on the pediatric patients treated by the hospital’s endocrinology team to see how they were faring in life. He said he thought that was quite odd, so had decided to take on the project himself. He began by asking, “so, D_____, [I went by another name then] how are you doing at this point in your life?”I felt a sudden surge of rage, and, to my own surprise, I found myself responding angrily, “Why the hell do you care? It’s been over ten years and nobody, I mean nobody gives a rat’s ass as to how I’m doing and coping with the ramifications of the treatment I received from Dr. X.” Looking back, more than ten years after this meeting, I can see that I had been angry for a long time. I had been compliant and knew to play my role as a good girl. I had a good job, and I was married, but I knew I was far from happy.And so with that first question began what would be the long painful journey to discovering what had been hidden from me for over half my life, the source of my confusion and unparalleled frustration. What I had experienced throughout my childhood would permeate every aspect of my being and perception of myself for years to come. Every day I had to confront the effects of that experience just to live another day.The MiddleI was in shock and disbelief as I read and reread the letter my attorney presented to me from the very group of... (shrink)