The article focuses on talk and cognition in terms of action. It outlines methodological alternatives for approaches addressing meaning construction and the accounts people give of their actions. There are studies, rooted especially in phenomenology and ethnomethodology, that manifest the idea of intersubjective reality seen as achievements of situated actions. In this framework, conversation and communication are seen per se as significant forms of social action. Instead of intersubjective reality, often brought about with an inductive research method, the article (...) argues for instrumental reality as the context for understanding talk and cognition in terms of action. The aim is a method that studies multivoicedness of activity in terms of situated actions. The method integrates situational features in dialogue with the cultural-historical processes of meaning construction. It is based on the theoretical notion of activity as a system that emerges and changes in time and place through internal contradictions. In the context of instrumentality, dialogical processes are also considered historically emerging and internally conflicting processes of rationality. I discuss this method with data on conversations between a patient and a doctor at a primary health care consultation. The study considers medical knowledge less as a substance than as a historically produced perspective through which the rationality of problem solving is accomplished by doctor and patient. The study aims to break away from the epistemological dualism of conflicting domains of meaning: the one of medicine that is objective and the one of experience that is subjective. The context of instrumentality includes a working hypothesis of a zone of proximal development of the doctor-patient relationship. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:“Can They Do This?” Dealing with Moral Distress after Third–Party Termination of the Doctor–Patient RelationshipSusan McCammonNot so long ago, a storm badly damaged the tertiary care hospital in which I practice surgical oncology. In the aftermath of the storm, the institution determined it was no longer able to provide unreimbursed cancer care, and many of my patients were terminated by a form letter from the hospital. The helplessness (...) and outrage that I experienced when I was first handed one of these letters, crumpled from the damp fist of one of my patients, was immense, and frightening in its unfamiliarity: “Can they do this?” I asked repeatedly, ascending a hierarchy of authority, which was increasingly reticent and then elusive. In short, the answer was “yes.”While this decision was made by the administration, its enactment was delegated to the physicians. Thus, not only were the physicians not involved in the decision to terminate their patients, they shouldered the burden of telling their patients that they would no longer be treated. The reason given—storm devastation—was contradicted by the orderly flow of insured patients in and out of unaffected clinics and hospitals.In those months, when the operating rooms were closed, I took to the road and learned about hospice and palliative care medicine on the ground. I drove from city to smaller city to the devastated countryside, locating my patients and providing all the care that I could with only my hands and mind and heart. I struggled with the limitations of the health care system and worked to rebuild a sustainable infrastructure at my own institution, all while trying to come to terms with bioethicist Haavi Morreim’s (1995) caution that “... it is not the physician who owes the resources at all. He cannot owe what others own and control, because moral obligations can only be assigned to those capable of fulfilling them” (p. 87).In considering my experience of moral distress over this period of time, I have reflected on the different connotations of the word, “practice.” I grappled with the philosophical terms “practice,” “praxis,” and “phronesis,” and I questioned their relevance to the word, as used in my professional life. However, in struggling to understand my moral obligations after the storm, when I was learning to do what I could, even when I couldn’t do what I felt like I should, I reconsidered. The elements of immersion, repetition, particularity, and utility that pervade this language of philosophers and artists turned out to be what preserved my ability [End Page 109] to practice medicine in a space holding only patient and practitioner.Many of the patients that I take care of are very poor. Many more are working but uninsured. This is a result of both their risk factors and the demographics and resources in my geographic catchment area. Their access to care was disrupted after a natural disaster and concerted efforts to reestablish it have not succeeded. Since then, I have learned how to tell people that they will die of cancer because they don’t have enough money. This is not a skill I was taught in medical school. I can talk about death, imminent or not, feared or anticipated. I can talk about unresectable tumors, treatments that have more risk than benefit (or no benefit at all), suffering beyond what has yet been experienced or imagined, helplessness, futility and grief. I could be neither surgeon nor oncologist without some facility with these. But I was unprepared for this move from medical to economic “can’t,” the nexus where an institutional “won’t” becomes a personal “can’t.”I should say here that I was not blind to the expense and technological hype of the American medico–industrial complex or our systematic marginalization of public health or the ever–present cries for health care reform. I understood that I was a steward and that I served both the individual and the society and had at my disposal what I was told were limited resources. These values, however, were only just being incorporated into the training of medical professionals; certainly they played no role in my own education. Morreim’s (1995) conclusion... (shrink)

In this paper we discuss expected and reported effects on care provider-patient relations of the introduction of electronic patient records (EPRs) in consultation settings by reviewing exemplary studies and literature on the subject from the past decade. We argue that in order for such assessments to be meaningful, talk of effects of “the” EPR needs to be replaced by an “unpacking” of EPR systems into their constituent parts and functionalities, the effects of which need to be assessed individually. Following (...) from this principle, the paper discusses EPR systems ranging from simple data entry and retrieval systems to more sophisticated multi-user and multifunctional on-line systems. On a second level, our analysis of the literature is informed by the question which model of ideal patienthood underlies the assessment of effects of EPRs. To this end, we identify three “models of patienthood” implicit in writing about benefits and drawbacks of EPRs for patients: the autonomy, the consumer, and the holistic models, and argue that assumptions concerning these models need to be reflected upon more critically to improve understanding of what exactly EPR use does to the doctor-patient relationship. (shrink)

Without any warning, in September 1999, David Newman was told he had a rare and life-threatening tumor in the base of his skull. In the compressed space of five weeks, he consulted with leading physicians and surgeons at four major medical centers. The doctors offered drastically differing opinions; several pronounced the tumor inoperable and voiced skepticism about the effectiveness of any nonsurgical treatment. _Talking with Doctors_ is the story of Newman's efforts, at a time of great stress and even impending (...) death, to wend his way through the dense thicket of medical consultations in search of a physician and a treatment that offered the possibility of survival. It is the story, especially, of the harrowing process of assessing conflicting "expert" opinions and, in so doing, of making sense of the priorities, personalities, and vulnerabilities of different doctors. All too often, he found, the leading specialists to whom he was sent were strangers in the consulting room-and strangers who became stranger still, both cognitively and emotionally, when ambiguous findings pushed them to the outer limits of their training and experience. Newman writes poignantly of his sense of powerlessness and desperation, of the painstaking means by which he ascertained what could be known about his tumor, and of the fortuitous events that finally led him to life-saving help. _Talking with Doctors_ is a compelling, absorbing, unsettling story that touches a collective raw nerve about the experience of doctors and medical care when life-threatening illness leads us to subspecialists at major medical centers. Probing the nature of medical authority and the grounds of a trusting doctor-patient relationship, Newman illuminates with grace and power what it now means for a patient to participate in life-and-death medical decisions. (shrink)

In this paper we discuss expected and reported effects on care provider-patient relations of the introduction of electronic patient records (EPRs) in consultation settings by reviewing exemplary studies and literature on the subject from the past decade. We argue that in order for such assessments to be meaningful, talk of effects of “the” EPR needs to be replaced by an “unpacking” of EPR systems into their constituent parts and functionalities, the effects of which need to be assessed individually. Following (...) from this principle, the paper discusses EPR systems ranging from simple data entry and retrieval systems to more sophisticated multi-user and multifunctional on-line systems. On a second level, our analysis of the literature is informed by the question which model of ideal patienthood underlies the assessment of effects of EPRs. To this end, we identify three “models of patienthood” implicit in writing about benefits and drawbacks of EPRs for patients: the autonomy, the consumer, and the holistic models, and argue that assumptions concerning these models need to be reflected upon more critically to improve understanding of what exactly EPR use does to the doctor-patient relationship. (shrink)

The last time you went to your doctor, you might have emerged feeling dissatisfied and disoriented. Nothing was clear after you left the office, and you don’t know whether it’s your fault or the doctor’s. While patients need to take control of the visit and set their agenda, the latest research shows that doctors and patients need to connect on a more emotional level as well. -/- In Talking to Your Doctor, readers will learn to: -/- •Talk to your (...) doctor—and get your doctor to talk to you • Remake the relationship with your doctor, and our health care system, on the basis of good communication •Make sure your visit with the doctor is productive and meets your needs •Help yourself and others avoid over-testing and over-treatment -/- Starting with the conversation can redress imbalances and put the relationship of doctor and patient, and eventually the entire health care system, back on a healthy footing. Using illuminating model dialogues, real transcripts from the clinic and hospital, resources for communication improvement, and a brief history of doctor-patient communication, the author helps readers develop strategies for obtaining better care from their doctors, from the minute they step into the exam room. (shrink)

A view from a student: ethical teaching, based on ethical guidelines, is at odds with clinical practice. Is this poor practice, or is the ethical guidance too simple?

For the past 45 years a passionate debate has been going on about whether doctors should be allowed or forbidden to bring their consciences—defined as their religious beliefs and moral convictions—into the exam room.1 Focusing explicitly or implicitly on abortion and assisted suicide, this debate has made it almost impossible to talk about conscience in a broader way. And yet it is critical to do so today, as huge corporations take over medicine and, with it, power over doctors' actions.Here, (...) then, I will explore "conscience" in a different way, not as a set of religious beliefs or moral convictions, but as I experience it, as an inner sense of rightness and falseness. My argument will be that to not heed that... (shrink)

Japan is among the few countries that have passed laws concerning eugenics. Consequently, the practice of selective abortion (abortion of an abnormal foetus) has been publicly debated for the past 35 years. Nevertheless, data show that knowledge in Japan about prenatal diagnosis is anything but common. In my fieldwork (April- June 2006) only 38% of interviewees (13/34) knew or had heard of 'amniocentesis' and 6% knew nothing about it at all. There are many explanations for why people are unaware of (...) prenatal diagnosis. The most crucial factor is that medical doctors do not talk to their patients about it. My interviews with 11 medical doctors revealed that they do not talk about it because they want to respect the principle of patient selfdetermination. In this paper I aim first to introduce and analyse, in the context of Japanese eugenic history and the contemporary notion of the patient-doctor relationship, medical doctors' explanations for not talking to their patients about amniocentesis. Second, I address whether the principle of 'non-intervention' equates to 'self-determination'. Lastly, I suggest possible improvements to the practice of 'self-determination' in Japan. (shrink)

In recent years, the opioid crisis in the United States has sparked significant discussion on doctor–patient interactions concerning chronic pain treatments, but little to no attention has been given to investigating the vocal aspects of patient talk. This exploratory sociolinguistic study intends to fill this knowledge gap by employing prosodic discourse analysis to examine context-specific linguistic features used by the interlocutors of two distinct medical interactions. We found that patients employed both low pitch and creak as linguistic resources (...) when describing chronic pain, narrating symptoms and requesting opioids. The situational use of both features informs us about the linguistic ways in which patients frame fraught issues like chronic pain in light of the current opioid crisis. This study expands the breadth of phonetic analysis within the domain of discourse analysis, serving to illuminate discussions surrounding the illocutionary role of the lower vocal tract in expressing emotions. (shrink)

Nurses need to adapt to various interactional situations and design their talk for different recipients. One essential communicative task for nurses is to transmit information on test and measurement results both to the patient and to the physician. This article examines how nurses design their talk on numerical values according to the recipient and the activity. The nurse can deliver the information either plainly through numbers or by formulating some type of qualitative description of the value. The data (...) consist of 7.5 hours of video-recorded interaction in a Finnish hospital. Using conversation analysis, we demonstrate how the institutional roles and the ongoing activity sequence affect how nurses formulate their talk. When nurses discuss results with their patients, they typically use qualitative descriptions, whereas when they talk with doctors, the typical turn involves numeric information. It will be demonstrated that nurses construct their professional identity involving both care and medical expertise through their linguistic-interactional choices. (shrink)

For more than sixty years, surgeons have used bioethical strategies to promote patient self‐determination, many of these now collectively described as “informed consent.” Yet the core framework—understanding, risks, benefits, and alternatives—fails to support patients in deliberation about treatment. We find that surgeons translate this framework into an overly complicated technical explanation of disease and treatment and an overly simplified narrative that surgery will “fix” the problem. They omit critical information about the goals and downsides of surgery and present untenable options (...) as a matter of patient choice. We propose a novel framework called “better conversations.” Herein, surgeons provide context about clinical norms, establish the goals of surgery, and comprehensively delineate the downsides of surgery to generate a deliberative space for patients to consider whether surgery is right for them. This paradigm shift meets the standards for informed consent, supports deliberation, and allows patients to anticipate and prepare for the experience of treatment. (shrink)

The puzzling case of the broken arm -- Hernias, diets, and drugs -- Why physicians cannot know what will benefit patients -- Sacrificing patient benefit to protect patient rights -- Societal interests and duties to others -- The new, limited, twenty-first-century role for physicians as patient assistants -- Abandoning modern medical concepts: doctor's "orders" and hospital "discharge" -- Medicine can't "indicate": so why do we talk that way? --"Treatments of choice" and "medical necessity": who is fooling whom? -- Abandoning (...) informed consent -- Why physicians get it wrong and the alternatives to consent: patient choice and deep value pairing -- The end of prescribing: why prescription writing is irrational -- The alternatives to prescribing -- Are fat people overweight? -- Beyond prettiness: death, disease, and being fat -- Universal but varied health insurance: only separate is equal -- Health insurance: the case for multiple lists -- Why hospice care should not be a part of ideal health care I: the history of the hospice -- Why hospice care should not be a part of ideal health care II: hospice in a postmodern era -- Randomized human experimentation: the modern dilemma -- Randomized human experimentation: a proposal for the new medicine -- Clinical practice guidelines and why they are wrong -- Outcomes research and how values sneak into finding of fact -- The consensus of medical experts and why it is wrong so often. (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)

Background: There is little research comparing clinicians’ and managers’ views on priority settings in the healthcare services. During research on two different qualitative research projects on healthcare prioritisations, we found a striking difference on how hospital executive managers and clinical healthcare professionals talked about and understood prioritisations. Aim: The purpose of this study is to explore how healthcare professionals in mental healthcare and somatic medicine prioritise their care, to compare different ways of setting priorities among managers and clinicians and to (...) explore how moral dilemmas are balanced and reconciled. Research design and participants: We conducted qualitative observations, interviews and focus groups with medical doctors, nurses and other clinical members of the interdisciplinary team in both somatic medical and mental health wards in hospitals in Norway. The interviews were recorded and transcribed verbatim. Ethical considerations: Basic ethical principles for research ethics were followed. The respondents signed an informed consent for participation. They were assured anonymity and confidentiality. The studies were approved by relevant ethics committees in line with the Helsinki Convention. Findings: Our findings showed a widening gap between the views of clinicians on one hand and managers on the other. Clinicians experienced a threat to their autonomy, to their professional ideals and to their desire to perform their job in a professional way. Prioritisations were a cause of constant concern and problematic decisions. Even though several managers understood and empathised with the clinicians, the ideals of patient flow and keeping budgets balanced were perceived as more important. Discussion: We discuss our findings in light of the moral challenges of patient-centred individual healthcare versus demands of distributive justice from healthcare management. Conclusion: The clinicians’ ideals of autonomy and good medical and nursing care for the individual patients were perceived as endangered. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:My Patient, TeacherMarissa BlumI remember meeting Beatriz about 12 years ago when security was called to her office visit room by the fellow doctor-in-training who was seeing her. She was yelling loudly about her pain medications, causing a terrific commotion. I stepped in to relieve the fellow and tried to calm her down and move the visit along without anyone getting hurt or further upset. And from then on, (...) Beatriz was moved to my schedule from the fellow's for her monthly visits for her knee pain and refills of fentanyl and oxycodone. She had terrible knees and walked with a cane, almost always accompanied by her son. At one point, she came to our clinic asking to be seen but couldn't, and then fell onto her knees and rolled onto her back in the wait-room, clutching and waiving her cane, expelling expletives and railing at anyone who wanted to help but denying them that privilege. It was as though she relished exposing her pain and a lifetime of hardship for all to confront. I came down from my office to talk with her and when I couldn't convince her to get up on her own, we called EMS to assist and they took her away in an ambulance.For the first few years, I recoiled seeing her name on my schedule each month. I knew I would have to endure a barrage of labile emotions and complaints not just about her constant pain and feelings of inadequacy of her pain medications, but also about her other doctors and how they don't respond to her, or about how the rest of her family shows no care for her. Initially, these visits were hard because they were unpredictable and Beatriz also had bipolar disorder and maybe borderline personality too. I never knew which type of Beatriz I would walk in to see: Angry, tearful, lamentful, and all of those faces were difficult for me. But we met every month for years. During those visits, which almost always were attended by her son, who quietly sat by to either gently rebuff or passively agree with her, I learned so much about her and her very hard life. She was left to raise two children alone, unskilled and ill with hepatitis C, which led to liver cancer, followed later by breast cancer. She chose not to pursue additional therapy for breast cancer, expressing a fatalistic view of her life and intimating she in some way deserved the ailments that she developed. She saw me for disabling knee and hip arthritis that took away her independence and ability to scale the outdoor steps to her second-floor apartment and required the assistance of her son to dress, bathe and care for her. Beatriz never knew this, and I didn't share [End Page 18] it with her, but on one of my early morning drives into North Philadelphia, I saw her on a sun-baked unfriendly street, struggling to move around with her walker. She had many reasons to be angry, and the 30 minutes I spent with her every month became a catharsis for her to unload all that she felt.During my medical training, I encountered hundreds of patients—mostly all in the hospital setting—who might be characterized as difficult and understandably; no one who is relegated to the hospital setting, acutely or chronically ill and requiring inpatient care, could possibly be in the best mood of their lives. Somehow, it was easier for me to care for patients in these snapshot encounters that I controlled. I dictated my time in the room and didn't necessarily have to encounter the same challenging patient longitudinally, which made certain encounters much easier to bear. I realize now I wasn't fully processing the burdens carried by these patients in a way that enabled me to be a compassionate and fully present physician to them. It was an adaptation to the fast-paced life of residency, where one just has to get the job done and move on to the next task without time to process or reflect on difficult patient interactions. This is a... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Tincture of the Doctor's TimeHolland KaplanI first thought of Mr. H as a "difficult patient" while reading the written hand-off I received on him as I was preparing to take over an inpatient general medicine service—"He leaves all the time to smoke." I don't think the statement was meant to imply anything about the patient; if anything, it may have been included for context to prepare me for (...) the patient's intermittent absence. But, reading this, I felt a familiar sense of annoyance rising in my chest. Every few months, I take care of a patient who seems to never be in his room. The patient is consistently out smoking, in the cafeteria, or in another unknown location, seemingly doing an undisclosed activity. This is frustrating because it means I have to work around the patient's schedule of smoke breaks and jaunts to the cafeteria to evaluate the patient on a daily basis. The thoughts inevitably cross my mind: Does this patient even want care in the hospital if he's never in his room? Is he actually sick enough to need to be in the hospital if he's able to spend so much time outside of the hospital? Why is he leaving so frequently—is he doing drugs?This particular patient had been in perfect health until two months before I met him when he was shot multiple times during an encounter at a gas station. One of the bullets had lodged in his back, shattering a vertebra. Another had decimated the bones in his right upper arm, which were now held in place by screws and plates. Several had landed in his abdomen, necessitating the removal of part of his bowel. Finally, a bullet had sliced through the lower part of his right kidney, shredding his ureter and mandating surgical reconstruction of his urinary system. After over a month in the intensive care unit with multiple reparative surgeries, he was discharged to a rehabilitation facility. But he started having fevers and fast heart rates; ultimately, he was admitted to the hospital again for multiple infected fluid collections that had formed at the sites of his surgeries. He left the hospital prior to getting treated for these infections, purportedly "against medical [End Page 12] advice." And now, several weeks later, he was here in the hospital for the same reason.The first time I went to see Mr. H, he was, of course, not in his room. I went to the nursing station to ask if the clerk knew where he was. She knowingly said, "Oh yeah, he goes out a lot. I can give him a call to let him know the doctor is here to see him if you'd like." I assented, thanked the clerk for calling him, and proceeded, annoyed, in seeing the rest of my patients. I considered how I would address Mr. H's behavior when I was finally able to talk to him. I had seen others take many different approaches—negotiation about the timing and frequency of these extramural expeditions, ultimatums about getting discharged, mandating urine drug screens upon return, and silent, frustrated tolerance. I resolved to wait to speak to him to determine which approach might be most suitable. An hour later, I received a call from the clerk that Mr. H had returned to his room to see me.The first time I met Mr. H, he informed me he had taken the bus to midtown to make a run to the grocery store. I was internally incredulous. He felt well enough to go to the grocery store? Why was he in the hospital then? At that moment, I opted not to discuss his frequent departures yet, as I was frustrated and realized I wouldn't be able to identify the best way to address them. I reviewed his medical issues with him, asked specific questions about how he was feeling, performed a physical exam, and reiterated his current plan of care. Mr. H made it very clear that he would like to get out of the hospital as soon as possible. I tried to set the expectation that he... (shrink)

Most studies evaluating companion effects on medical triadic interaction focus on the doctors' part, e.g., how the companion's presence diverts doctors' attention away from the patient. In contrast to this mainstream approach, the current research proposes an alternative framework by focusing on the patient parties—especially on how companion participation reshapes the discourse sequences where patient parties provide information, and how it affects patient full turns and priority in providing complete first-hand information to doctors. By examining fifteen geriatric triadic conversations collected (...) in a teaching hospital in southern Taiwan, this proposed framework concludes that in the companion's presence, the information providing sequences are restructured into eight patterns, among which sole information provider is preferred to joint providers. Furthermore, the more companions participate in providing information, the less patients by themselves volunteer information or respond to doctors' questions prior to companions' verbal involvement. A more striking companion effect shows that even in the triads with a low-participation companion, whenever the companion does participate, the patient rarely has a full turn or priority to complete an information unit. The patient's turns are either taken, are simultaneous with, or cut-off by the companion's participation. (shrink)

The paper examines the attainment and adequacy of informed consent in an ethnographic–discursive study on gynecological visits involving doctors, patients, and nurses. Starting from a theoretical discussion on informed consent and the principles upon which it relies, the paper highlights the changes and the adjustments that these principle undergo in practice, from the planning of the research till later stages of the researcher’s fieldwork and data recording. Analyses first focus on the informed consent as a written artifact and show how (...) the description of the study indexes the prospective participants’ identity, as well as, it works in favor of the researcher’s (or, other institutional representatives such as the managers of the Hospital) accountability. Then, the authors focus on instances of audio and video recorded doctor–patient–nurse interactions in which information is reformulated by the doctors, in such a way as to anticipate and/or respond to the nurses’ and patients’ concerns with regards the project (such as, the risk of exposure to the public). The analysis of these episodes carry ethical implications, in that they alert that patients, nurses, and doctors may be not equally knowledgeable about the project and that they can be conceded unequal opportunities to have their interpretations and identity performances acknowledged and inscribed on the tape. (shrink)

As a third-year medical student, I have the job of being the first person from the medical team to check in on patients in the morning, follow up on consults that they may need, and communicate with people from other services who are involved with patients’ care. Because third-year medical students have the most time of anyone on the medical team, we are encouraged to get to know our patients. We are encouraged to take time to understand our patients’ conditions (...) on both a medical and personal level, that is, both to read about their complex diseases and to talk about their preferences, goals, families, and lives outside the hospital. As best we can, we then communicate their personal needs and preferences to the medical team of doctors, nurses, social workers and others. What could be wrong with that? (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Vertical Transmission:The Patient, the Student, the TeacherMiguel PaniaguaHe did not ask for this fate, nor did he deserve it, particularly considering the tragic circumstances. Lì presented to the campus health provider one month prior with fatigue, abdominal pain, and jaundice. He and his parents immigrated to the United States from China when he was a child. He was well aware that he had hepatitis B from what is termed (...) "vertical transmission." His mom unknowingly passed on this virus to him during her pregnancy. In most countries with a high prevalence of the virus, prenatal screening is routinely undertaken, and prophylaxis administered. I am not certain this occurred in Lì's case and at this point it did not matter. Lì knew he would live with this for the duration of his life. In fact, he told me he had gone his whole life to this point without any symptoms whatsoever. What is known about chronic hepatitis B infection is that in most people affected, it can be considered a chronic disease where most live a long full life. The risk of advancing to liver cirrhosis or cancer in general is low. This unfortunately was not the case with Lì.What transpired was what they most feared. As he was studying for his final exams, Lì endured days of worsening fatigue, malaise, and nausea. He noticed his skin was a tinge of yellow and he was having some itching that was unusual. He noticed his clothes fitting more loosely and found he had unintentionally lost twenty pounds. He visited the campus health center and after a series of tests and imaging studies, Lì was diagnosed with advanced hepatocellular carcinoma, an unfortunate sequela of this chronic infection. It was then that he put school on hold and returned home to get further care.I first met Lì in the hospital as a consultant for the palliative medicine service. "He won't listen." "He is so difficult." "He is in denial." These were examples of some of the care team's exasperated assessments of his demeanor as a patient. What I did not realize prior to visiting him the first time was that Lì was a pre-clinical medical student. When I first met him, he did not want to talk very much; he was preoccupied and distant. In retrospect, I can see that he was suffering on so many levels. His appearance was gaunt and cachectic. The lights in the room cast shadows in the concave areas of his temples and his collarbones were the most prominent feature of his torso through his hospital gown. He glowed yellow from jaundice. When I examined him on this first visit, I noticed that his liver, a now grossly enlarged hard and nodular structure, occupied most of his abdomen. I found that speaking to him as a colleague, even calling him "doctor," helped him feel respected and enabled me to build rapport with him. At one point, I described to him the findings I felt in his abdomen. "I can palpate the edge of your liver here, what seems to be eight centimeters below your costal margin. There are many palpable nodularities on the ventral surface." It was at this point I invited him to palpate what I was feeling. I gently guided his own hand over his abdomen and noticed him studying the features as if they were not his own, like a skilled diagnostician.Over the course of three weeks, I visited with Lì when I was on service. The last time I saw him, he had declined rapidly, his disease progressing [End Page 17] cruelly, and he was very short of breath and becoming more somnolent. I noticed his mother in the room, standing by his bed, and crying inconsolably as he lay suffering. I felt deep anguish and remorse, wondering if she said these words to herself "It is all my fault," considering the source of his initial illness. I cannot even imagine.As I assisted the team in titrating his comfort medications, I sat with him. He shook my hand with all the strength left that he could muster and said, "you are a good doctor." I... (shrink)

Background: Studies from Western countries show that doctors working in neonatal intensive care units find withdrawal of treatment to be their most difficult ethical dilemma. There is less knowledge of how this is experienced in other economic, cultural, religious and educational contexts.Objectives: To explore and describe how Indian doctors experience ethical dilemmas concerning the withdrawal of treatment among critically sick and/or premature neonates.Method: Qualitative data from interviews was analysed according to Giorgi's phenomenological approach. The subjects were 14 doctors with various (...) levels of neonatal experience, recruited from two state‐owned NICUs in India. Main outcome measures: description reflecting the nature of ethical dilemmas and how they are experienced.Results: All doctors reported situations where the question of withdrawal of treatment was experienced as the worst part of their job. They felt that they lacked training in how to handle such dilemmas, and some had never talked about ethics before. They were especially concerned about non‐medical considerations that do not feature in current treatment guidelines. In describing their personal experiences, the informants mentioned their sense of responsibility in situations where they were aware that their decisions would influence a family's economy and reputation, availability of food and education for siblings, other children's access to equipment in the unit, and the use of resources in an underprivileged population. Sometimes lack of resources, usually ventilators, forced them to make decisions about which babies should get the chance to live. Other reported dilemmas included difficulties co‐operating with uneducated and poor parents.Conclusion: While Western doctors seem to focus on the rights and problems of the individual child, Indian doctors tend to refer to consequences for other children, for parents and society. There is a need for further research in this field, and for the development of guidelines on how to cope with differences in resources, and how to handle different patient groups’ cultural and religious concerns. (shrink)

I write this article as a postgraduate researcher undertaking a doctorate in Education, with an interest in research as a transformative process, and fascinated by the debate as to whether reality is objective or subjective. In reflecting on this, I recalled a significant incident that occurred when I was Professional Education Lead in an NHS hospital. I had been asked to work with a nurse, who had been disciplined as a consequence of talking about her Christian faith with a patient. (...) The nurse was assuming that, in sharing experiences that were transformative for her, she might also transform the patient’s perception of her own illness and its meaning. As a Christian myself, I was caught in a situation where I could understand the conflicting perspectives of all key players, including the patient, her family, the nurse, and the NHS managers. I explore how I mediated my way through this situation, aiming to do justice to all perspectives, and the ethical dilemmas I faced when having to choose between personal and professional values. As a consequence of this incident, I have learned that, not only is transformation a deeply personal experience, but because it is either influenced by, or leads to, a specific world view, it supports the idea of reality being subjective rather than objective. (shrink)

BackgroundDefensive practice occurs when physicians provide services, such as tests, treatments and referrals, mainly to reduce their perceived legal or reputational risks, rather than to advance patient care. This behaviour is counter to physicians’ ethical responsibilities, yet is widely reported in surveys of doctors in various countries. There is a lack of qualitative research on the drivers of defensive practice, which is needed to inform strategies to prevent this ethically problematic behaviour.MethodsA qualitative interview study investigated the views and experiences of (...) physicians in Australia on defensive practice and its contribution to low value care. Interviewees were recruited based on interest in medico-legal issues or experience in a health service involved in ‘Choosing Wisely’ initiatives. Semi-structured interviews averaged 60 min in length. Data were coded using the Theoretical Domains Framework, which encapsulates theories of behaviour and behaviour change.ResultsAll participants (n = 17) perceived defensive practice as a problem and a contributor to low value care. Behavioural drivers of defensive practice spanned seven domains in the TDF: knowledge, focused on inadequate knowledge of the law and the risks of low value care; skills, emphasising patient communication and clinical decision-making skills; professional role and identity, particularly clinicians’ perception of patient expectations and concern for their professional reputation; beliefs about consequences, especially perceptions of the beneficial and harmful consequences of defensive practice; environmental context and resources, including processes for handling patient complaints; social influences, focused on group norms that encourage or discourage defensive behaviour; and emotions, especially fear of missing a diagnosis. Overall, defensive practice is motivated by physicians’ desire to avoid criticism or scrutiny from a range of sources, and censure from their professional peers can be a more potent driver than perceived legal consequences.ConclusionsThe findings call for strengthening knowledge and skills, for example, to improve clinicians’ understanding of the law and their awareness of the risks of low value care and using effective communication strategies with patients. Importantly, supportive cultures of practice and organisational environments are needed to create conditions in which clinicians feel confident in avoiding defensive practice and other forms of low value care. (shrink)

As the single most important experience in the lives of all people, the process and event of death must be handled carefully by the medical community. Twentieth-century advances in life-sustaining technology impose new areas of concern on those who are responsible for dying persons. Physicians and surrogates alike must be ready and willing to decide not to intervene in the dying process, indeed to hasten it, when they see the autonomy and dignity of patients threatened. In addition, the very ways (...) we talk about death and dying need to come under scrutiny, and it is likely that our technical advances should be parallelled by equally arduous advances in the semantic and rhetorical approaches we take to death. (shrink)

Non-compliance is a label often used about patients who do not follow therapeutic advice. This paper analyses the notion of compliance, and tries to show that this notion is inextricably bound to a paternalistic conception of the doctor-patient relationship. It is proposed that we should perhaps not talk so much about the non-compliant patient, but instead shift the focus towards the non-compliant doctor.

Artificial intelligence (AI) plays a rapidly increasing role in clinical care. Many of these systems, for instance, deep learning-based applications using multilayered Artificial Neural Nets, exhibit epistemic opacity in the sense that they preclude comprehensive human understanding. In consequence, voices from industry, policymakers, and research have suggested trust as an attitude for engaging with clinical AI systems. Yet, in the philosophical and ethical literature on medical AI, the notion of trust remains fiercely debated. Trust skeptics hold that talking about trust (...) in nonhuman agents constitutes a category error and worry about the concept being misused for ethics washing. Proponents of trust have responded to these worries from various angles, disentangling different concepts and aspects of trust in AI, potentially organized in layers or dimensions. Given the substantial disagreements across these accounts of trust and the important worries about ethics washing, we embrace a diverging strategy here. Instead of aiming for a positive definition of the elements and nature of trust in AI, we proceed ex negativo, that is we look at cases where trust or distrust are misplaced. Comparing these instances with trust expedited in doctor–patient relationships, we systematize these instances and propose a taxonomy of both misplaced trust and distrust. By inverting the perspective and focusing on negative examples, we develop an account that provides useful ethical constraints for decisions in clinical as well as regulatory contexts and that highlights how we should not engage with medical AI. (shrink)

In the theater the fictional Dr. Kelekian’s relief that he does not have to talk to family members about his patient’s cancer treatment draws uneasy laughter from the audience. Doctors, patients, and family members alike recognize the situation, even if hearing it so baldly expressed discomfits them.Why do physicians and other health care professionals, including lawyers and bioethicists, so often view families as “trouble”? And why do families so often see medical professionals as uncaring and uncommunicative? Presumably everyone wants (...) the same goal—recovery or the best possible outcome for the patient. And yet trouble clearly exists. We do not see the problem as one of “dysfunctional families” or “callous doctors,” although there are undoubtedly many of each. (shrink)

When natural time sequences were replaced by clocks, time became a measurable commodity and the ‘speedy use of time’ a virtue. In medical practice shorter consultations allow more patients to be seen, whereas longer consultations result in a better understanding of the patient and her problems. Crossing the line of time-efficiency and time-effectiveness compromises the balance between short-term turnover and long-term outcomes. The consultation has all the hallmarks of a complex adaptive system whose characteristics are not determined by the characteristics (...) of the components, but by the patterns of interaction among the components. Systems are dynamic and change over time; the dynamic nature is not incidental, but necessary as complex systems operate at conditions far from equilibrium. The central notion when we talk of time and complexity is that of ‘memory’. Memory is carrying something from the past over into the future. Memory is filtered/interpreted, separating noise from information. Memory therefore is not an instantaneous thing, it takes time to develop; it is slow. The dynamics between the participating agents in the consultation will create shared memories that live on to shape future interactions. Shared memories are stronger and contain more relevant knowledge if they are based on frequent interactions and ongoing doctor–patient relationships, leading to a better understanding of the whole person – a process that takes time. Sufficient time, that is, ‘a certain slowness’, is an essential element of the healing relationship in the consultation. It creates a sufficiently stable, but adaptive, environment that can withstand changing demands. Hence a more complete understanding of the consultation and its time demands will not only lead to more effective treatment, it will also humanize a situation which has become to a large extent purely instrumental. This process of humanization is important not only for the patient, but also for the doctor. (shrink)

An incisive examination of bioethics and American healthcare, and their profound affects on American culture over the last sixty years, from two eminent scholars. An eye-opening look at the inevitable moral choices that come along with tremendous medical progress, Everybody Wants to Go to Heaven but Nobody Wants to Die is a primer for all Americans to talk more honestly about health care. Beginning in the 1950s when doctors still paid house calls but regularly withheld the truth from their (...) patients, Amy Gutmann and Jonathan D. Moreno explore an unprecedented revolution in health care and explain the problem with America’s wanting everything that medical science has to offer without debating its merits and its limits. The result: Americans today pay far more for health care while having among the lowest life expectancies and highest infant mortality of any affluent nation. Gutmann and Moreno—“incisive, influential, and pragmatic thinkers” (Arthur Caplan)—demonstrate that the stakes have never been higher for prolonging and improving life. From health care reform and death-with-dignity to child vaccinations and gene editing, they explain how bioethics came to dominate the national spotlight, leading and responding to a revolution in doctor-patient relations, a burgeoning world of organ transplants, and new reproductive technologies that benefit millions but create a host of legal and ethical challenges. With striking examples, the authors show how breakthroughs in cancer research, infectious disease, and drug development provide Americans with exciting new alternatives, yet often painful choices. They address head-on the most fundamental challenges in American health care: Why do we pay so much for health care while still lacking universal coverage? How can medical studies adequately protect individuals who volunteer for them? What’s fair when it comes to allocating organs for transplants in truly life-and-death situations? A lucid and provocative blend of history and public policy, this urgent work exposes the American paradox of wanting to have it all without paying the price. (shrink)

The conception of the doctor–patient relationship under Australian law has followed British common law tradition whereby the relationship is founded in a contractual exchange. By contrast, this article presents a rationale and framework for an alternative model—a “Trust Model”—for implementation into law to more accurately reflect the contemporary therapeutic dynamic. The framework has four elements: an assumption that professional conflicts with patient safety, motivated by financial or personal interests, should be avoided; an onus on doctors to disclose these conflicts; (...) a proposed mechanism to contend with instances where doctors choose not to disclose; and sanctions for non-compliance with the regime. (shrink)

This article reports the results of a survey, by mailed questionnaire, of the attitudes, values and practices of doctors in Singapore with respect to the doctor-patient relationship. Questionnaires were sent to a random sample of 475 doctors (261 general practitioners and 214 medical specialists), out of which 249 (52.4%) valid responses were completed and returned. The survey is the first of its kind in Singapore. Questions were framed around issues of medical paternalism, consent and patient autonomy. As the doctors were (...) exposed to Western ethical concepts in their training, we were not surprised to find that they would mostly allow patients some say in decision-making and keep patients reasonably informed. In respecting patient autonomy, they would usually seek to influence patient choice by persuasion. However, the residual "Asian-ness" of doctors in Singapore gives rise to some inconsistencies between values and practices. Many doctors still believe that a number of their patients are incapable of rational choice. There is some lack of openness in telling patients the whole truth. When patients choose to refuse treatment, many doctors are prepared to involve family members in making a consensus decision. Doctors were also asked how they made ethical judgements in the face of dilemmas, and how they would like disputes with patients to be resolved. By and large, the doctors prefer to make their own judgements rather than to rely on rules. They also wish to keep the law courts out of disputes with patients, preferring less public ways of settling disputes. (shrink)

In recent philosophy of mind a non-holistic view on concept possession, originally developed by Tyler Burge, has emerged as an alternative to holistic analyses of language mastery. The article discusses the implications of this view for analyses of communication in doctor—patient-interaction. The central question Burge's theory gives an answer to is this: to what extent must a doctor and a patient understand a medical term in the same way in order to communicate in the sense that they express the same (...) concept by the term? Many empirical studies have shown that patients do not, typically, understand medical terms in the same way as doctors they encounter. Holistic approaches therefore imply that doctors and patients seldom communicate. Burge's position, on the other hand, implies that it is sufficient that patients have a minimal understanding. In an important range of cases doctors can make sure that patients have a minimal understanding by being explicit about common dictionary definitions of the terms in question. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Misprision of IdentityHarold Merskey (bio)Misprision the deliberate concealment of one's knowledge of a crime...A misreading, misunderstanding, etc.A failure to appreciate the value of a thing...(Concise Oxford Dictionary)There are options in the forms of identity that Charland's subjects assume. There are options as well in the meaning of this title, which may apply severally or individually to the choices under consideration. Are those who change their identity with labels—or reject (...) labels—correctly assuming accurate descriptions, or incorrectly misleading themselves and some others? In which of these cases are observation and intervention ethical, and do they pose demands on medical ethicists, or should they simply be ignored?Types of AutonomyParticipants in chat rooms on the Internet may justifiably be considered to be individuals who are seeking a current method of communication to promote a view of themselves, or ideas that they possess, or projects that they endorse. In this they may resemble others who have used more traditional methods of presenting their ideas, their claims, their wares, hard merchandise, literary material, or political or philosophical propositions to the public at large. These others may be sales persons, advertisers, poets, singers, clowns, buskers, politicians, preachers, missionaries, learned public speakers, television presenters, news commentators (but not necessarily reporters), and anyone indeed who talks to other people in public about matters that she or he wishes to bring forward. They have a point they want to make. They may be grouping themselves as 'survivors' or pro-anorexia, or Multiple Personality Disorder victims, but they are not necessarily operating as patients who are looking for a fiduciary relationship with physicians or other health care practitioners. It is thus a long step to turn them into individuals who may have a claim on the doctor–patient relationship.Do we wish to undertake research on them? Research or study in the first instance for these circumstances must be in the field of social science. The rules of what it is ethical for a sociologist to do apply first. The rules of situations where one person has more power and the other depends on that individual for assistance without exploitation may differ considerably from case to case. In so far as there may be some special rules as to what is fair, reasonable, just, kind, merciful, or prudent to study individuals who expose themselves and their interests publicly, this is perhaps best done first by reference to standards for journalists.That criterion may be too lenient a standard for most health professionals because journalists seem to be quite willing to expose the subjects of their observations to public obloquy and to [End Page 351] present information about many individuals—information that the persons themselves do not consent to see in the public domain, but that the journalist, having acquired, feels entitled to make known. Still there are believed to be some standards that journalists observe and these tend to protect the weak and the more vulnerable, although that does not mean that they are regularly followed. They tend to emphasize not printing material that is salacious or very lewd and would have personal reference, but they do not withhold comparable information if they consider that it is accurate and describes the behavior of individuals who are of interest to the public which, in certain circumstances, may mean almost anybody.So up to this point it seems that our normal respect for the autonomy of the individual in chat rooms can be balanced against our interest in freedom of speech, which leads to open and very broadly based publication of information and observations.The Burden of the LabelOnce the medical label is affixed, a different level of stringency begins to apply to what may be studied or published. Because we feel that individuals' self-esteem is at risk and perhaps their lives, we hesitate to make cutting or pejorative comments about distressed people. Such diagnoses as cancer or depression may be held back from the patient (and, certainly, in the case of depression, even more may be kept from others around the patient). Likewise unspoken thoughts may be automatically acknowledged and, like radical material, may be carefully segregated and... (shrink)

Medical doctors arrive at a diagnosis after considering various types of evidence, including the patient's complaints, their outer appearance, talk, and non-verbal behavior. In psychiatry, the role of conversation is more important than in somatic medicine, because it is in the patient's talk that the disease can express itself. Some elements of the conversational machinery have been studied in diagnostic interviews in a psychiatric ward. In the interviews, a recurrent pattern of the doctor’s questions and the patient’s answers (...) was found. Schegloff (2007) showed that “known answer” questions form a distinctive three-part sequence type: question-response-evaluation. In diagnostic interviews in psychiatry, the questions don't address knowledge but the capacity to perform the task. Not all the test questions have a correct answer, and the result of the evaluation is not always announced by the doctor. The doctor consistently repeats the patient’s answer without evaluating it and then adds a follow-up question. At least parts of the repeated cycles in the sequence of doctor-patient interaction exhibit the following pattern: Doctor’s question > Patient’s answer > Doctor’s echo > (optional Doctor's follow-up question). When the doctor's questions seek real information—and do not just test capacity—they sometimes resort to a reformulation of the patient’s answers instead of just repeating it; this reformulation works as a prompt. The questions in the clinical interview appear to follow two lines of accountability: the ordinary conversational order and that which is provided by the professional reasoning aimed at checking diagnostic hypotheses. The second line is not usually accessible to the patient. (shrink)

The nature of the doctor-patient relationship as a keystone of care necessitates philosophical, psychological and sociological considerations. The present study investigates concepts related to these three critical views considered especially important. From the philosophical viewpoint, the three concepts of "the demands of ethics “,” ethical phenomenology and "the philosophy of the relationship" are of particular importance. From a psychological point of view, the five concepts of "communication behavior patterns", "psychic distance", "emotional quotient", "conflict between pain relief and truth-telling", and "body (...) language" have received specific emphasis. Lastly, from the sociological perspective, the three notions of "instrumental action", "communicative action", and "reaching agreement in the light of communicative action" are the most significant concepts to reconsider in the doctor-patient relationship. It should be added, however, that from the sociological point of view, the doctor-patient relationship goes beyond a two-person interaction, as the moral principles of doctors and patients depend on medical and patient ethics respectively. The theoretical foundations of the doctor-patient relationship will finally help establish the different dimensions of medical interactions. This can contribute to the development of principles and multidisciplinary bases for establishing practical ethical codes and will eventually result in a more effective doctor-patient relationship. (shrink)

The growth of managed care was accompanied by concern about the impact that changes in health care organization would have on the doctor-patient relationship. We now are in a “post-managed care era,” where some of these changes in health care delivery have come to pass while others have not. A re-examination of the DPR in this setting suggests some surprising results. Rather than posing a new and unprecedented threat, managed care was simply the most recent of numerous strains on the (...) DPR that have occurred throughout the century. These strains are a constant, inevitable consequence of the varying needs and concerns of patient and physicians as they seek to balance their desires for a certain type of DPR with their simultaneous desire for other aspects of care such as lower costs, greater technological sophistication, and improved outcomes. (shrink)

The merit of Plato’s Laws remains largely untapped by those seeking genuinely collaborative models of the doctor–patient tie as alternatives to paternalism and autonomy. A persistent difficulty confronting proposed alternatives has been surpassing the notion of pronounced intellectual and values asymmetry favoring the doctor. Having discussed two prominent proposals, both of which evince marked paternalism, I argue that reflection on Plato yields four criteria that a genuinely collaborative model must meet and suggest how the Laws addresses them. In the (...) process, the Laws’ doctor–patient tie is shown to be far more nuanced than interpreters have previously observed. Although Plato’s account will not solve our own quandaries, it illustrates how one might retain asymmetry of a kind without capitulating to familiar oppositional modalities. Through this account, I hope to show that the Laws merits fuller inclusion in contemporary discussions than it has heretofore received. (shrink)

The author offers grounds for preferring a `fiduciary' model of the doctor-patient relationship to either an `authoritative' or a `contractual' model. Within this framework he suggests that certain acts of euthanasia could be accommodated not in any way as duties, but as supererogatory acts of kindness to the patient.

Boundaries in the doctor–patient relationshipis an important concept to help healthprofessionals navigate the complex andsometimes difficult experience between patientand doctor where intimacy and power must bebalanced in the direction of benefitingpatients. This paper reviews the concept ofboundary violations and boundary crossings inthe doctor–patient relationship, cautions aboutcertain kinds of boundary dilemmas involvingdual relationships, gift giving practices,physical contact with patients, andself-disclosure. The paper closes with somerecommendations for preventing boundaryviolations.

In an analysis of recent work on nudging we distinguish three positions on the relationship between nudging founded in libertarian paternalism and the protection of personal autonomy through informed consent. We argue that all three positions fail to provide adequate protection of personal autonomy in the clinical context. Acknowledging that nudging may be beneficial, we suggest a fourth position according to which nudging and informed consent are valuable in different domains of interaction.

Background: Doctor–patient sexual relationship is considered to be unfair because the first party would be abusing the second party’s vulnerability. The prohibition of this relationship is noted in the Hippocratic oath. Currently, a reprise of the use of oaths in medical schools can be observed.Aim: To determine whether the prohibition has been maintained and how its expression has varied in the oaths during different periods.Methods: 50 oaths were studied: 13 ancient–medieval and 37 modern–contemporary. Of the 50 texts, 19 were (...) versions of the original oaths. The oaths that pointed out the prohibited doctor–patient relationship referred to any sexual aspect or included paragraphs that began as the Hippocratic oath does were noted.Results: Of the 24 texts that expressed the prohibition, 8 were ancient–medieval and 16 were modern–contemporary. Some expressly call it Hippocratic oath, many use general terminology and others describe it in association with other commitments .Conclusions: The clause on the prohibition of the doctor–patient sexual relationship in Hippocratic oath was included to be for legal, economic and social reasons at the time. That the clause is found mostly in the ancient–medieval oaths can be attributed to the influence of the original. This commitment is generalised and associated with others by contemporary formulas. Currently, sexual relationships are the subject of legal and ethical analysis and their inclusion in the oaths is being debated. (shrink)

Trust in the doctor-patient relationship is an indispensable structural element for the medical profession. The discourse concerning trust and its importance in the healthcare context, although quite old, elicits increasingly more interest in research, especially for empirical approaches. The importance of trust in the doctor and in the medical profession can be demonstrated by starting from the Christian meaning of illness and medicine ; generally, the patristic sources see medicine and physicians as God’s gifts. T he perception of Christian physicians (...) as dedicated, unselfish and compassionate preservers or restorers of health, always committed to the good of their patients is well known. The model of the Christian physician is a Hippocratic model, of one who seeks the sick so that he may bring relief to them and strengthen them. When illness occurs, Christianity affirms an ethical duty to struggle against sickness, which if unaddressed can lead to death. The moral requirement to care for the health of the body indicates it is appropriate to use healing methods that will enhance health and maintain life. The aim of this paper is to explore the dimensions of the concept of trust in the doctor-patient relationship, by starting from the Christian meaning of illness and of the role of the doctor. The paper presents a number of essential theoretical elements related to trust, as presented in the literature dealing with the doctor-patient relationship: the meaning of trust, its dimensions, its stages of development, its impact, its sources, the patient’s perspectives on trust, the importance of trust for healthcare systems. (shrink)

Artificial intelligence (AI) based clinical decision support systems (CDSS) are becoming ever more widespread in healthcare and could play an important role in diagnostic and treatment processes. For this reason, AI‐based CDSS has an impact on the doctor–patient relationship, shaping their decisions with its suggestions. We may be on the verge of a paradigm shift, where the doctor–patient relationship is no longer a dual relationship, but a triad. This paper analyses the role of AI‐based CDSS for shared decision‐making (...) to better comprehend its promises and associated ethical issues. Moreover, it investigates how certain AI implementations may instead foster the inappropriate paradigm of paternalism. Understanding how AI relates to doctors and influences doctor–patient communication is essential to promote more ethical medical practice. Both doctors' and patients' autonomy need to be considered in the light of AI. (shrink)