Canada is a leader in experimenting with alternative, non fee for service provider remuneration methods; all jurisdictions have implemented salaries and payment models that blend fee for service with salary or capitation components. A series of qualitative interviews were held with 27 stakeholders in the Canadian health care system to assess the reasons and expectations behind the implementation of these payment methods for family physicians, as well as the extent to which objectives have been achieved. Results indicate that the (...) main reasons are a need to recruit and retain primary care physicians to rural and remote regions of the country, and the desire to increase collaboration, care continuity, prevention and health promotion. The general perception is that positive results have been observed, but problems are not alleviated. Blended payments have had some positive effects on preventive care delivery, collaboration, and care continuity. Salaries have provided a stable, predictable, and high source of income for physicians, thereby improving recruitment and retention. The implementation of salaries, however, led to concerns with declining physician productivity, and has brought to light a need for improved measurement and monitoring systems. (shrink)

In Martin v. Ortho Pharmacetrtical Corp. ), the Supreme Court of Illinois held that, although a federal regulation requires pharmaceutical manufacturers to provide direct warnings to consumers about the dangers associated with oral contraceptives, this regulation does not constitute an exception to the learned intermediary doctrine and the manufacture will not be held strictly liable. The court declined to recognize an exception for manufacturers of contraceptives due to important policy considerations and the legislative intent underlying the learned intermediary (...) doctrine. The doctrine is based on the assumption that prescribing physicians, not pharmaceutical manufacturers, are in the best position to provide direct warnings to patients concerning the dangers associated with prescription drugs. The decision may affect patients whose medical care providers are unable to account for drug propensities or patient susceptibilities. Additionally, patients with forgetful or inarticulate health care providers are at risk. (shrink)

This qualitative research examines the influence of animosity on physicians during clinical encounters and its ethical implications. Semi-structured interviews were conducted with ten Israeli-Jewish physicians: four treated Syrians and six treated Palestinian terrorists/Hezbollah militants or Palestinian civilians. An interpretive phenomenological analysis was used to uncover main themes in these interviews. Whereas the majority of physicians stated they are obligated to treat any patient, physicians who treated Syrians exhibited stronger emotional expression and implicit empathy, while less referring (...) to the presence of the Israeli-Arab conflict. In contrast, physicians who treated enemy combatants or Palestinian civilians showed the exact opposite. Linking these results to the “Implicit Bias” theory, the role of empathy and the beneficence principle in medical ethics, we argue that: the unconscious decreased emotional involvement among the latter group of physicians is a deficiency that needs to be recognized; and this deficiency undermines the principle of beneficence, thereby possibly influencing the fulfillment of the commitment to treat patients. Acknowledging and addressing the potential emotional and ethical deficiencies entailed in encounters with the so-called enemy-patients are of importance to the global medical community, since such encounters are increasingly an integral part of the current political realities faced by both the developed and developing worlds. (shrink)

At the conclusion of their 1968 report, the Harvard Ad Hoc Committee argued that “responsible medical opinion” was ready to accept severe and permanent neurologic injury as a new criterion for deat...

In lieu of an abstract, here is a brief excerpt of the content:Lessons Learned in Room 208Katherine BakkeAuthor's Note. Parts of this story were previously shared here: https://theinterstitium.home.blog/2020/06/01/journeying-to-a-time-of-death/I remember the first time I saw a patient die. I was a medical student on my surgery rotation. Pushed to the sidelines of the resuscitation bay while the trauma team tended to a teenager injured in a motorcycle crash, my attention was drawn to the drama unfolding next door. There, a team (...) of physicians performed CPR on a man. While a curtain and a comforting social worker separated the patient's wife and daughter from the horrors of the resuscitation, I had a full view of everything. I watched as each chest compression threw the man's belly upward, like he had a bad bout of the hiccups. I watched as each pulse check yielded no return of blood flow. I watched as his wife and daughter clenched their hands in prayer, muttering, "Please, please, please." Then, the physician called the code. The instant the doctor pronounced him dead, I felt the presence of one less person in the room. I was surprised by how visceral this departure felt. It seemed like a sacred moment, a small proof that our bodies do indeed house our souls.I started paying close attention to how surgeons talked about death. Discussions of death seemed frequent in windowless work rooms amongst doctors, or in hushed conversations at the nurses station. Discussions of death were notably absent when talking with patients or their families. Sometimes, it seemed that the sicker the patient, the less likely their possible death was acknowledged. I [End Page E12] was fascinated by how challenging it was to speak honestly about our inevitable mortality. I began reading everything I could find about discussing end-of-life issues. I even conducted and published a systematic review on the subject. When it came time for me to begin my own surgical training, I carried with me a naive confidence, eager to engage in these conversations at the bedside.My time finally came eight months into my intern year. I was working in the intensive care unit and was "up" for the next admission. I got a call from the emergency department, saying a 68-year-old woman needed an ICU bed for a heart failure exacerbation. Her breathing was labored. They had given her IV Lasix, but I was told she might need BiPAP or other respiratory support while her heart failure was managed.Ten minutes later, she rolled into Room 208, and the ICU nurses started their work transferring her from the stretcher to the bed, applying EKG leads, a blood pressure cuff, and a pulse oximeter. I stood at the foot of the bed and quickly realized I had never taken care of a patient so ill. Her head drooped to her chest, every ounce of energy used to draw her next breath. She could only mumble indiscernible words; she hardly had the energy to open her eyes. I glanced at the monitor displaying her vitals: heart rate 120, SpO2 84%, BP 70/40. A foley catheter hung at the bedside, and no urine was present. "They gave her Lasix downstairs, right?" I asked the nurse. We both looked at the foley bag, and then at each other. I glanced at the patient's lips, which were dry and cracked. I pinched the skin at the top of the patient's hand, and it tented. I was pleased with my exam skills, and my ability to deduce that she was dehydrated. "This isn't heart failure," I thought, as I considered other reasons for her illness. The nurse awoke me from my self-congratulating stupor and reminded me sternly, "We need orders."The situation rapidly became more critical. The patient's arterial blood gas (ABG) showed a pattern of impending respiratory failure. Her daughters arrived at the bedside; one was wearing hospital scrubs. I introduced myself to them as the resident doctor caring for their mom. I asked if the daughter wearing scrubs had a healthcare background, foolishly thinking that doing so would build rapport. She curtly replied, "I... (shrink)

Background: An ongoing challenge for clinical ethics consultation is learning how colleagues in other healthcare professions understand, make use of, and evaluate clinical ethics consultation services. Aim: In pursuing such knowledge as part of clinical ethics consultation service quality assessment, clinical ethics consultation services can learn important information about the issues and concerns that prompt colleagues to request ethics consultation. Such knowledge allows for greater outreach, education, and responsiveness by clinical ethics consultation services to the concerns of clinician colleagues. Design: (...) This quality assessment project explores consultation requests and follow-up questionnaire responses voluntarily submitted from nurses who requested clinical ethics consultation. We present qualitative data analyzed using content analysis and constant comparison methods to identify key concerns that prompted requests as well as common themes among nurse requestors’ evaluations of what was most important in clinical ethics consultations. Participants and context: A total of 41 nurses requesting clinical ethics consultation and 15 who returned the follow-up questionnaire. Ethical considerations: Our Office of Research Compliance and Quality Improvement determined that our project was not considered human subjects research and so did not require institutional review board approval or exemption. However, efforts were made to avoid any sense of coercion and all data were de-identified prior to analysis. Findings: Our analysis revealed six main categories of issues that prompted nurses’ requests for ethics consultation, as well as unifying themes around nurses’ experiences, advocacy, and family support while caring for patients in the intersections of patients, families, and physicians. Discussion: The insights gained from analyzing nurses’ requests for and responses to clinical ethics consultation may serve as a resource for clinical ethics consultation services seeking to identify, respond to, and educate regarding issues of importance to nurse colleagues and may be a resource for nursing administrators and leadership seeking to identify and address common ethical issues nurses face. Conclusion: Ongoing work on clinical ethics consultation service quality improvement and engagement with our nursing colleagues about their concerns prompting—and their evaluations of—clinical ethics consultation are necessary. (shrink)

Conflicts of interest are rampant in the American medical community. Today it is not uncommon for doctors to refer patients to clinics or labs in which they have a financial interest (40% of physicians in Florida invest in medical centers); for hospitals to offer incentives to physicians who refer patients (a practice that can lead to unnecessary hospitalization); or for drug companies to provide lucrative give-aways to entice doctors to use their "brand name" drugs (which are much more (...) expensive than generic drugs). In Medicine, Money and Morals, Marc A. Rodwin draws on his own experience as a health lawyer--and his research in health ethics, law, and policy--to reveal how financial conflicts of interest can and do negatively affect the quality of patient care. He shows that the problem has become worse over the last century and provides many actual examples of how doctors' decisions are influenced by financial considerations. We learn how two California physicians, for example, resumed referrals to Pasadena General Hospital only after the hospital started paying $70 per patient (their referrals grew from 14 in one month to 82 in the next). As Rodwin writes, incentives such as this can inhibit a doctor from taking action when a hospital fails to provide proper service, and may also lead to the unnecessary hospitalization of patients. We also learn of a Wyeth-Ayerst Labs promotion in which physicians who started patients on INDERAL (a drug for high blood pressure, angina, and migraines) received 1000 mileage points on American Airlines for each patient (studies show that promotions such as this have a direct effect on a doctor's choice of drug). Rodwin reveals why the medical community has failed to regulate conflicts of interest: peer review has little authority, state licensing boards are usually ignorant of abuses, and the AMA code of ethics has historically been recommended rather than required. He examines what can be learned from the way society has coped with the conflicts of interest of other professionals --lawyers, government officials, and businessmen--all of which are held to higher standards of accountability than doctors. And he recommends that efforts be made to prohibit and regulate certain kinds of activity (such as kickbacks and self-referrals), to monitor and regulate conduct, and to provide penalties for improper conduct. Our failure to face physicians' conflicts of interest has distorted the way medicine is practiced, compromised the loyalty of doctors to patients, and harmed society, the integrity of the medical profession, and patients. For those concerned with the quality of health care or medical ethics, Medicine, Money and Morals is a provocative look into the current health care crisis and a powerful prescription for change. (shrink)

This paper argues that the world-wide debate about physician assisted dying is missing a golden opportunity to focus on the orchestration of the end of life. Such a process consists of far more than adequate pain control and is a skill which, like all other skills, needs to be learned and taught. The debate offers an opportunity to press for the teaching of this skill. Beyond this, the desire to assure that all can have access to palliative care makes (...) sense only within the embrace of a universal health-care system and the desire that all can have a death with dignity is meaningful only within the embrace of a life with dignity. (shrink)

In this article, by professional immunity we refer to limitation of liability to the specific pandemic context, respectively to the concrete possibilities of diagnosis, treatment, care and too few degrees of professional freedom still available. The relevance of one or another of the limitation measures of professional liability depends on the specific legal context of each community. Our thesis is that, regardless of the form of transposition into practice, a form of health professionals protection, such as professional immunity is necessary. (...) From the multitude of possible protection measures, each state can select the appropriate ones. The need for specific measures for professional immunity is not identical in each state, depending on the specifics of the legal system, social values, measures characteristics taken to combat the pandemic, the degree of transparency of each healthcare system, the level of bioethical principles influence. However, this need doesn`t start from "no measure", the appropriate minimum level of protection seemingly to constitute a patient compensation no-fault model, plus the characteristics of the professional immunity, designed to adapt liability to specific conditions. The main problem in the absence of professional immunity is the risk of transferring the cost of ignorance, visible, in the inadequate expectations of medical science, on healthcare professionals, the limits of scientific knowledge risking to be reinterpreted as medical fault. The COVID-19 pandemic has somehow forced an additional step towards broadening discussions on universal human rights, being forced to consider ways of putting them into practice in the context of limited resources. Assuming that the increase in social complexity increases the risks of such events, we approach these problems from the perspective of creating rapid mechanisms to adapt to such changes, the lessons learned now being applied in the future to other similar cases. (shrink)

Background The COVID-19 pandemic causes moral challenges and moral distress for healthcare professionals and, due to an increased work load, reduces time and opportunities for clinical ethics support services. Nevertheless, healthcare professionals could also identify essential elements to maintain or change in the future, as moral distress and moral challenges can indicate opportunities to strengthen moral resilience of healthcare professionals and organisations. This study describes 1) the experienced moral distress, challenges and ethical climate concerning end-of-life care of Intensive Care Unit (...) staff during the first wave of the COVID-19 pandemic and 2) their positive experiences and lessons learned, which function as directions for future forms of ethics support. Methods A cross-sectional survey combining quantitative and qualitative elements was sent to all healthcare professionals who worked at the Intensive Care Unit of the Amsterdam UMC - Location AMC during the first wave of the COVID-19 pandemic. The survey consisted of 36 items about moral distress (concerning quality of care and emotional stress), team cooperation, ethical climate and (ways of dealing with) end-of-life decisions, and two open questions about positive experiences and suggestions for work improvement. Results All 178 respondents (response rate: 25–32%) showed signs of moral distress, and experienced moral dilemmas in end-of-life decisions, whereas they experienced a relatively positive ethical climate. Nurses scored significantly higher than physicians on most items. Positive experiences were mostly related to ‘team cooperation’, ‘team solidarity’ and ‘work ethic’. Lessons learned were mostly related to ‘quality of care’ and ‘professional qualities’. Conclusions Despite the crisis, positive experiences related to ethical climate, team members and overall work ethic were reported by Intensive Care Unit staff and quality and organisation of care lessons were learned. Ethics support services can be tailored to reflect on morally challenging situations, restore moral resilience, create space for self-care and strengthen team spirit. This can improve healthcare professionals’ dealing of inherent moral challenges and moral distress in order to strengthen both individual and organisational moral resilience. Trial registration The trial was registered on The Netherlands Trial Register, number NL9177. (shrink)

The aim of the present study was to describe and explore the perception of ethical guidelines and their role in ethical competence-building among Swedish physicians and research nurses. Twelve informants were interviewed in depth. The results demonstrated that the informants had a critical attitude towards ethical guidelines and claimed to make little use of them in practical moral judgements. Ethical competence was seen primarily as character-building, related to virtues such as being empathic, honest and loyal to patients. Ethical competence (...) was assumed to be learned through good examples, role models and practical experience, while ethical guidelines were not perceived as valuable in this process. In order to improve the staff's familiarity with and the usability of ethical guidelines, the workplace needs to provide opportunities for ethical dialogues. In such discussions, argumentation can improve, virtues can be developed and guidelines can be usefully invoked. (shrink)

DNR decisions are frequently made in oncology and hematology care and physicians and nurses may face related ethical dilemmas. Ethics is considered a basic competence in health care and can be understood as a capacity to handle a task that involves an ethical dilemma in an adequate, ethically responsible manner. One model of ethical competence for healthcare staff includes three main aspects: being, doing and knowing, suggesting that ethical competence requires abilities of character, action and knowledge. Ethical competence can (...) be developed through experience, communication and education, and a supportive environment is necessary for maintaining a high ethical competence. The aim of the present study was to investigate how nurses and physicians in oncology and hematology care understand the concept of ethical competence in order to make, or be involved in, DNR decisions and how such skills can be learned and developed. A further aim was to investigate the role of guidelines in relation to the development of ethical competence in DNR decisions. Individual interviews were conducted with fifteen nurses and sixteen physicians. The interviews were analyzed using thematic content analysis. Physicians and nurses in the study reflected on their ethical competence in relation to DNR decisions, on what it should comprise and how it could be developed. The ethical competence described by the respondents related to the concepts being, doing and knowing. In order to make ethically sound DNR decisions in oncology and hematology care, physicians and nurses need to develop appropriate virtues, improve their knowledge of ethical theories and relevant clinical guidelines. Ethical competence also includes the ability to act upon ethical judgements. Continued ethical education and discussions for further development of a common ethical language and a good ethical working climate can improve ethical competence and help nurses and physicians cooperate better with regard to patients in relation to DNR decisions, in their efforts to act in the best interest of the patient. (shrink)

Myriad Genetics holds a patent on testing for the hereditary breast and ovarian cancer genes, BRCA1 and BRCA2, and therefore has a forced monopoly on this critical genetic test. Myriad launched a Direct-to-Consumer (DTC) marketing campaign in the Northeast United States in September 2007 and plans to expand that campaign to Florida and Texas in 2008. The ethics of Myriad's patent, forced monopoly and DTC campaign will be reviewed, as well as the impact of this situation on patient access and (...) care, physician liability, and the future of DTC campaigns for genetic testing. (shrink)

Two decades of research on euthanasia in the Netherlands have resulted into clear insights in the frequency and characteristics of euthanasia and other medical end-of-life decisions in the Netherlands. These empirical studies have contributed to the quality of the public debate, and to the regulating and public control of euthanasia and physician-assisted suicide. No slippery slope seems to have occurred. Physicians seem to adhere to the criteria for due care in the large majority of cases. Further, it has been (...) shown that the majority of physicians think that the euthanasia Act has improved their legal certainty and contributes to the carefulness of life-terminating acts. In 2005, eighty percent of the euthanasia cases were reported to the review committees. Thus, the transparency envisaged by the Act still does not extend to all cases. Unreported cases almost all involve the use of opioids, and are not considered to be euthanasia by physicians. More education and debate is needed to disentangle in these situations which acts should be regarded as euthanasia and which should not. Medical end-of-life decision-making is a crucial part of end-of-life care. It should therefore be given continuous attention in health care policy and medical training. Systematic periodic research is crucial for enhancing our understanding of end-of-life care in modern medicine, in which the pursuit of a good quality of dying is nowadays widely recognized as an important goal, in addition to the traditional goals such as curing diseases and prolonging life. (shrink)

Some weeks ago, we learned that the matriarch of a family, my good friend Anna, is dying. She is 75 and has inoperable esophageal cancer, and the doctors say it will only take a few more weeks or months. Anna is dying the way I want to die–at home, surrounded and lovingly tended by her family: her devoted husband of 54 years, her three daughters, her three worshipful sons-in-law, her adoring granddaughters. All of them see her every day. All (...) of them are a part of a mutual struggle to give Anna a “good death” Anna, too, is a part of it. And, in a very small way, I am part of it, because I have been invited to be. Every few days, I walk next door and spend a few minutes talking to Anna. (shrink)

Given the wide-reaching and detrimental impact of COVID-19, its strain on healthcare resources, and the urgent need for—sometimes forced—public health interventions, thorough examination of the ethical issues brought to light by the pandemic is especially warranted. This paper aims to identify some of the complex moral dilemmas faced by senior physicians at a major medical centre in Saudi Arabia, in an effort to gain a better understanding of how they navigated ethical uncertainty during a time of crisis. This qualitative (...) study uses a semistructured interview approach and reports the findings of 16 interviews. The study finds that participants were motivated by a profession-based moral obligation to provide care during the toughest and most uncertain times of the pandemic. Although participants described significant moral dilemmas during their practice, very few identified challenges as ethical in nature, and in turn, none sought formal ethics support. Rather, participants took on the burden of resolving ethical challenges themselves—whenever possible—rationalising oft fraught decisions by likening their experiences to wartime action or by minimising attention to the moral. In capturing these accounts, this paper ultimately contemplates what moral lessons can, and must be, learnt from this experience. (shrink)

Professional medical ethics demands of health care professionals in addition to specific duties and rules of conduct that they embody a responsible and trustworthy personality. In the public discussion, different concepts are suggested to describe the desired implied attitude of physicians. In a sequel of three articles, a set of three of these concepts is presented in an interpretation that is meant to characterise the morally emotional part of this attitude: “empathy”, “compassion” and “care”. In the first article of (...) the series, “empathy” has been developed as a mainly cognitive and morally neutral capacity of understanding. In this article, the emotional and virtuous core of the desired professional attitude—compassion—is elaborated. Compassion is distinguished from sympathy, empathy and pity. Several problems of compassion as a spontaneous, warm emotion for being a professional virtue are discussed: especially questions of over-demand, of justice and of concerns because of a possible threat to the patient’s dignity and autonomy. An interpretation of compassion as processed and learned professional attitude, that founds dignity on the general idea of man as a sentient being and on solidarity, not on his independence and capacities, is developed. It is meant to rule out the possible side effects and to make compassion as a professional attitude and as professional virtue attractive, teachable and acquirable. In order to reach the adequate warmth and closeness for the particular physician-patient-relation, professional compassion has to be combined with the capacity of empathy. If appropriate, the combination of both empathy and compassion as “empathic compassion” can demand a much warmer attitude towards the patient than each of the elements alone, or the simple addition of them can provide. The concept of “care” that will be discussed in a forthcoming article of this sequel is a missing necessary part to describe the active potential of the desired moral attitude of the physician more completely. The reconstruction of the desired professional attitude in terms of “empathic compassionate care” is certainly not the only possible description, but it is a detailed proposal in order to give an impulse for the discussion about the inner tacit values and the meaning of medicine and clinical healthcare professions. (shrink)

Two decades of research on euthanasia in the Netherlands have resulted into clear insights in the frequency and characteristics of euthanasia and other medical end-of-life decisions in the Netherlands. These empirical studies have contributed to the quality of the public debate, and to the regulating and public control of euthanasia and physician-assisted suicide. No slippery slope seems to have occurred. Physicians seem to adhere to the criteria for due care in the large majority of cases. Further, it has been (...) shown that the majority of physicians think that the euthanasia Act has improved their legal certainty and contributes to the carefulness of life-terminating acts. In 2005, eighty percent of the euthanasia cases were reported to the review committees. Thus, the transparency envisaged by the Act still does not extend to all cases. Unreported cases almost all involve the use of opioids, and are not considered to be euthanasia by physicians. More education and debate is needed to disentangle in these situations which acts should be regarded as euthanasia and which should not. Medical end-of-life decision-making is a crucial part of end-of-life care. It should therefore be given continuous attention in health care policy and medical training. Systematic periodic research is crucial for enhancing our understanding of end-of-life care in modern medicine, in which the pursuit of a good quality of dying is nowadays widely recognized as an important goal, in addition to the traditional goals such as curing diseases and prolonging life. (shrink)

Few studies exist which look at psychological factors associated with physician sexual misconduct. In this study, we explore family dysfunction as a possible risk factor associated with physician sexual misconduct. Six hundred thirteen physicians referred to a continuing medical education (CME) course for sexual misconduct were administered the FACES-II survey, a validated and reliable measure of family dynamics. The survey was part of a self-learning activity. We collected data from February 2000 to February 2009. Participants were predominantly white, middle-aged (...) males who represented the full range of medical specialties. Their results were compared against a sample of 177 physicians. The FACES-II is a self-report test that measures family of origin (the family in which one was raised) dynamics on two dimensions (1) flexibility, ranging from too flexible (chaotic) to not flexible enough (rigid) and (2) cohesion ranging from too close (enmeshed) to not close enough (disengaged). The most common family pattern observed among physicians accused of sexual misconduct was rigid flexibility paired with disengaged cohesion, indicative of unhealthy family functioning. This pattern was significantly different than the pattern observed in the comparison group. Physicians who engage in sexual misconduct are more likely to have family of origin dysfunction. Ethics is developmental and learned in one’s family of origin. Family of origin dynamics may be one risk factor predisposing one to ethical violations. These findings have important implications for screening, education, and treatment across the medical education continuum. (shrink)

The ArgumentIt is well known that theTractatusof Peter of Spain (later Pope John XXI) was one of the most popular logic textbooks in the Middle Ages and early Renaissance. Less known is theTractatus'sconsiderable reputation and diffusion among the Jews, as evidenced by five translations, two commentaries, and what appears to be anabbreviatio— if not of theTractatusitself, then of a similar work. The present article attempts to understand the phenomenon of theTractatus'spopularity and offers an analysis of the three translations whose authors (...) are known — those by Shemaryah ha-Ikriti (Greece, early to mid-fourteenth century), Abraham Abigdor (late fourteenth century), and Judah b. Samuel Shalom (either Italy or Spain, mid-fifteenth century) — and their subsequent fate. The more popular versions of Abraham Abidgor and Judah Shalom provided Jewish students, many of whom would likely become physicians, with a grounding in logic comparable to that of their Christian counterparts. (shrink)

Two decades of research on euthanasia in the Netherlands have resulted into clear insights in the frequency and characteristics of euthanasia and other medical end-of-life decisions in the Netherlands. These empirical studies have contributed to the quality of the public debate, and to the regulating and public control of euthanasia and physician-assisted suicide. No slippery slope seems to have occurred. Physicians seem to adhere to the criteria for due care in the large majority of cases. Further, it has been (...) shown that the majority of physicians think that the euthanasia Act has improved their legal certainty and contributes to the carefulness of life-terminating acts. In 2005, eighty percent of the euthanasia cases were reported to the review committees. Thus, the transparency envisaged by the Act still does not extend to all cases. Unreported cases almost all involve the use of opioids, and are not considered to be euthanasia by physicians. More education and debate is needed to disentangle in these situations which acts should be regarded as euthanasia and which should not. Medical end-of-life decision-making is a crucial part of end-of-life care. It should therefore be given continuous attention in health care policy and medical training. Systematic periodic research is crucial for enhancing our understanding of end-of-life care in modern medicine, in which the pursuit of a good quality of dying is nowadays widely recognized as an important goal, in addition to the traditional goals such as curing diseases and prolonging life. (shrink)

Two decades of research on euthanasia in the Netherlands have resulted into clear insights in the frequency and characteristics of euthanasia and other medical end-of-life decisions in the Netherlands. These empirical studies have contributed to the quality of the public debate, and to the regulating and public control of euthanasia and physician-assisted suicide. No slippery slope seems to have occurred. Physicians seem to adhere to the criteria for due care in the large majority of cases. Further, it has been (...) shown that the majority of physicians think that the euthanasia Act has improved their legal certainty and contributes to the carefulness of life-terminating acts. In 2005, eighty percent of the euthanasia cases were reported to the review committees. Thus, the transparency envisaged by the Act still does not extend to all cases. Unreported cases almost all involve the use of opioids, and are not considered to be euthanasia by physicians. More education and debate is needed to disentangle in these situations which acts should be regarded as euthanasia and which should not. Medical end-of-life decision-making is a crucial part of end-of-life care. It should therefore be given continuous attention in health care policy and medical training. Systematic periodic research is crucial for enhancing our understanding of end-of-life care in modern medicine, in which the pursuit of a good quality of dying is nowadays widely recognized as an important goal, in addition to the traditional goals such as curing diseases and prolonging life. (shrink)

IntroductionDignity therapy is brief psychotherapy targeting psychological and existential suffering among patients with a life-limiting illness. Studies have been conducted on the use of DT by healthcare professionals. In Italy, the current legislation defines that any form of psychotherapy may be performed exclusively by psychotherapists. Consequently, this intervention is unlikely to be used by other healthcare professionals. Herein, we will describe a training on DT not as a psychotherapy intervention but as a narrative intervention for non-psychotherapists health care professionals. Finally, (...) we will explore the potential enablers/barriers as experienced by palliative care physicians and nurses.MethodsThe study was conducted in the Psycho-Oncology Unit within the Cancer Research Hospital of Reggio Emilia. It consisted of an exploratory qualitative case study. Data were collected employing observations and interview data and thematically analyzed.ResultsThe training was attended by six physicians and ten nurses and took place during two-afternoon sessions for 10 h. Two participants put their training into practice and administered DT under the supervision of a psychotherapist. Data analysis highlighted five overarching themes relating to the training experience and direct use of DT, namely, time required, psychological skills, patient’s disease awareness, patient’s life history, and distinguishing DT from Advance Care Planning.ConclusionPalliative care professionals found DT to be a valuable non-pharmacological hospital-based intervention to address the person beyond the patient and his clinical conditions. In our experience, considering that in Italy, psychotherapy is an intervention that psychotherapists can only perform, it can help organize different training on DT for psychotherapists and other healthcare professionals. (shrink)

Throughout the sixteenth century, learned physicians across Europe performed a diverse array of “trials” of phenomena and published reports about them. This essay traces the phrase “periculum facere” (“to make a trial”) and related terms through natural history investigations, drug testing, chymical analysis, and anatomical discoveries. Physicians used ancient precedents, their learned expertise, and pedagogical authority to anchor the epistemic status of their trials and incorporated the historical narratives of their trial-making within arguments to factual and (...) causal knowledge, even philosophical scientia. Developed from engagement with things, ancient texts, other healers, and students, this lively tradition of contrived, first-person empirical trials flourished in some academic institutions, especially the University of Padua. The frequency and visibility of sixteenth-century medical trials, especially in the education of hundreds of students annually, is essential evidence for understanding how experimentation came to be widespread in early modern Europe. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Journal of the History of Ideas 65.2 (2004) 191-211 [Access article in PDF] Oratory and Rhetoric in Renaissance Medicine Nancy G. Siraisi Hunter College In Renaissance medical practice rhetoric had an ambiguous reputation. Many authors warned physicians against use of persuasion or repeated some version of the truism that patients are cured not by eloquence but by medicines. On the other hand, physicians were also reminded that (...) by speaking well they helped patients to have confidence in their advice and to understand directions, which in turn facilitated cure.1 Yet some aspects of medical culture of the period between 1450 and 1600 seem profoundly attentive to rhetoric, at least as regards the use of language, performative elements, and the influence of these features in ancient models (most notably Galen himself).2 One area in which rhetoric had an unambiguous, acknowledged, and essential place was in the medical orations pronounced at university ceremonies. A sample follows: Pursuit of all these different things by study, investigation of obscurities with ingenuity, conquest of difficulties with industry, and—after penetrating into the very fibers of the earth and searching everywhere into the arcana of the whole of nature and from all herbs, fruits, trees, animals, gems, and even poisons—inquiry after remedies and the proper way to use them for all the ills of human life from so many authors, so many disciplines, and even from the very stars: these things, I say, [End Page 191] have uncovered so many hidden cures, been attained with such arduous powers of the mind, completed with so much effort of memory, offer so many things necessary for the health of the entire human race in common, that does not indeed [the entire enterprise of medicine] seem to have been superhuman and really in a certain way divine?3This nicely exuberant example of Renaissance medical rhetoric exemplifies the genre in several respects. The oration to which it belongs was originally delivered to an academic faculty of medicine by a physician; it shows the impact in medical settings of the revival of epideictic rhetoric, and its author drew on learned sources and commonplaces about medicine that belonged to a store of broadly humanistic erudition, shared both in and outside the medical profession. In fact the only truly distinctive feature of this passage is its author. It comes from Erasmus's Encomium medicinae, which he wrote in 1499 for a friend—a physician named Gysbertus—to deliver to the medical faculty of the University of Paris.4If Gysbertus was exceptionally fortunate in his ghost, many other surviving medical orations are internal products of medical faculties, the work of university masters or students of medicine. But whoever their authors, orations delivered in or written for an academic medical setting offer some telling illustrations both of the way in which certain kinds of humanistic interests and requirements came to penetrate medical learning and of the reaction of humanistic rhetoric to medicine. "Medical humanism" is usually understood to encompass both the core enterprise of intensive philological study, editing, and translation of Greek medical texts—never the occupation of more than a handful of hellenist scholars—and also the reception and scientific influence of the fruits of their labors among a wider medical audience. But Renaissance medicine was also a humanistic discipline in a much broader and more inclusive sense; that is, it both fostered and provided ample scope for the development among learned physicians of interests characteristic of humanistic culture in general: rhetoric, history, biography, fascination with remote peoples and places, and antiquarianism. At the same time, as the passage from Erasmus quoted [End Page 192] above demonstrates, humanists outside the medical profession interested themselves in medicine and controlled a stock of rhetorical commonplaces on the subject. To be sure, the penetration of terminology and concepts from medicine into the general culture long antedated the Renaissance.5 But the revival of rhetoric together with attention to ancient sources and commonplaces provided humanist observers with new tools for commenting, sometimes in quite specific and detailed terms, on the contemporary medical scene, a phenomenon... (shrink)

This essay explores an unstudied compendium to Margaret Cavendish’s 1655 Philosophical and Physical Opinions that was composed by the learned physician, plant anatomist, and secretary of the Royal Society, Nehemiah Grew. Despite the growing body of scholarship on Cavendish, minimal attention has been dedicated to her early reception. But studying this compendium provides some fascinating insights into how one of the foremost thinkers of her day read, emended, and manipulated her ideas. I propose that Grew turned to Cavendish’s work (...) when developing his substance theory in the years leading up to the publication of his 1682 The Anatomy of Plants, but that shifting intellectual tides led him to critique her version of material vitalism in his 1701 Cosmologia Sacra. Supported by a transcription of the compendium as an appendix, this article also sheds light on the role that early modern pedagogical techniques and memory tools played in shaping concepts of matter and mind. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Bernard Mandeville and the Therapy of “The Clever Politician”Harold J. CookAs the institutional authority of the learned physicians of Augustan London waned, new threats to the classical foundations of medical practice appeared. 1 Patients had more freedom to chose from a variety of practitioners and practices, giving both consumer demand and the advertising skills of suppliers an even more powerful hand in medical affairs. While the burgeoning (...) medical marketplace developed mostly because of the profound socio-economic and political changes of the late Stuart period, intellectual transformations were at play, too. The new science appeared to encourage empiricism and the development of new remedies based on experimentation, devaluing university education in medical classics, but conversely the new science could strengthen physicians’ claims to superiority over mere patients and practitioners. Medical materialists, for instance, could turn the classical advisor/client relationship into that of an expert contolling a passive recipient (patient) for his or her own good.One contemporary debate that shows the implications of materialism for medical relationships is the theory of the passions. The passions linked mind and body. According to most classical accounts, one could (or should) control the passions by applying reason, resulting in both a virtuous and a healthy life. But according to a strong version of materialism, the mind could not hope to control the passions. A doctor therefore could no longer appeal to patients’ reason; rather, he had to manipulate the patient’s passions for his or her own good. Hence for a materialist, the doctor was not an adviser to the patient but an expert therapist, not a teacher of health and virtue but a “clever politician” who ordered bodily passions. Some versions of the new science, then, favored [End Page 101] the expertise of physicians while undermining older views about learned authority. Such an outlook is clear in the work of Dr. Bernard Mandeville, whose famous Fable of the Bees shows how the “clever politician” played on passions to make the body politic run smoothly. Mandeville held coherent views on politics, economics, moral philosophy, and medicine. Like many doctors of his time, he fought to establish his expertise in the new science. His views are expressed most clearly in the theory of the passions. By examining his discussion of the passions in both his social commentary and his medical dialogues, we can note similarities among his various writings and glimpse one of his fundamental positions on medicine and humanity.The Fable and its CriticsTo many English minds of the early eighteenth century, no one exemplified materialism’s threat better than Dr. Bernard Mandeville. Mandeville’s famous slogan, the subtitle of his Fable of the Bees—“private vices, public benefits”—seemed to epitomize materialism’s inherent immorality. The book seemed to argue that what most people recognized as human vices were the main engines of the collective good. Mandeville’s famous book pictured human nature as animalistic, in which the passions held sway over reason. In Mandeville’s world, it appeared, reason became little more than the ability to rationalize, the instrument of hypocrisy, merely letting people cover their true motives (grounded as they were in the passions) with empty words pretending to more exalted ends.His Fable had begun as a little, anonymous, satirical poem in 1705, titled “The Grumbling Hive: or, Knaves Turn’d Honest.” It began by speaking of “A Spacious Hive well stockt with Bees, / That liv’d in Luxury and Ease.” Many of the bees were knaves, with no calling free of deceit, but while “every Part was full of Vice, / Yet [was] the whole Mass a Paradise; /... Such were the Blessings of that State; / Their Crimes conspir’d to make them Great.” Avarice, prodigality, luxury, pride, envy, vanity, folly, fickleness, and inconstancy employed millions, encouraging ingenuity and industry and creating pleasures and comforts “To such a Height, the very Poor / Liv’d better than the Rich before.” But many of the thriving bees complained, shouting for honesty and virtue. When Jove “rid / The bawling Hive of Fraud,” economic collapse followed, with the consequent end of arts and sciences as well; population declined; the hive’s territory decreased; and the remaining bees toiled long and... (shrink)

This essay investigates the translatability of experience in seventeenth-century medical practica. It reconstructs the translation and the retranslation of the chapter on smallpox and measles taken from the immensely popular Praxis medica of Lazare Rivière. This text was adapted by two Jewish physicians: Jacob Zahalon, who translated it into Hebrew; and Abraham Wallich, who then modified it further. Both presented this work as their own. Reconstructing the decision making that went into their work, the essay argues that the erasure (...) of some practical and experiential content does not constitute a failure of translation but, rather, a reevaluation of the content’s applicability in a new context. The essay, dealing with Jewish learned physicians, also examines how different environments were reflected in these physicians’ writing. It therefore shows how physicians of comparable expertise resorted to dissimilar practices. (shrink)

This paper examines the inter-relationship between image, text and object in the Codex Kentmanus, which is one of the earliest records of the plants in the botanical garden at Padua, studied by Johannes Kentmann . The manuscript shows that “observation” for Kentmann involved a gradual process of assimilating knowledge from other physicians, apothecaries, and books in order to make the plants which were originally encountered at a specific time and place into a more generalised object of study for (...) class='Hi'>learned physicians. (shrink)

When physicians in training enter their clinical years and first begin to become involved in clinical decision making, they soon find that more than the technical data they had so carefully learned is involved. Prior to that time, of course, they were aware that more than technology was involved in practicing medicine, but here, for the first time, the reality is forcefully brought home. It may be on the medical ward, when a patient or a patient's relatives ask (...) that no further treatment be given and that the patient be allowed to die; it may be in ob/gyn, when a 4- or 5-month pregnant lady with two other children and just deserted by her husband pleads for an abortion; it may be in the outpatient setting, where patients unable to afford enough to eat cannot afford to buy antibiotics for their sick child or provide him or her with the recom mended diet. Whatever the setting, students soon find themselv. es con fronted with problems in which an answer is not given by the technical possibilities alone; indeed, students may have to face situations in which, all things considered, the use of these technical possibilities seems ill-advised. But choices need to be made. Some of us may choose to hide behind a mastery of technology. (shrink)

Physicians and other health care providers owe ethical and legal duties to patients to maintain the secrecy of the information learned during the course of patient care. This obligation is fulfilled by limiting access to such information to only those involved in the patient's care-that is, to those within the “circle of confidentiality.” As a general rule, providers may only disclose to others with the written prior consent of the patient. Exceptions may be “ethically and legally justified because (...) of overriding social considerations,” when permitted or compelled by law. For example, eleven states permit providers to disclose identified records to approved researchers.’ Many states compel disclosure in cases where a patient threatens serious bodily harm to another; require reporting to health or law enforcement authorities of communicable diseases, gunshot or knife wounds, or child abuse; and mandate reporting of cancer or other health care cases to state registries. (shrink)

Background This study assessed patient perceptions of the Physician Payments Sunshine Act and opinions toward physicians who receive gifts and/or payments from pharmaceutical or medical device companies. Methods During their office visit, patients attending different specialty clinics volunteered to complete our survey. The survey asks if the patient knows what the Sunshine Act is, then asks questions on 5-point response scales to assess the patient's opinions toward physicians who receive compensation from companies, their self-rated knowledge of physician compensation, (...) and how they believe this compensation affects the cost of care. Results Over 13 months, 523 responses were collected: 8.6% of patients reported having knowledge of the Sunshine Act, 56.8% rated their knowledge of physician compensations as “poor,” and 67.1% agreed with the statement that patients should be aware of the compensation physicians receive. When asked how their opinion toward their physician would change if they learned the physician received free meals or gifts from companies, 58.9% replied “not at all,” and 36.11% of patients did not believe their cost of care would increase if their physician received compensation from companies. Conclusions Most patients were unfamiliar with the Sunshine Act, and believe their knowledge of physician compensation is poor. Over half of the respondents would not change their opinion of their physician based on knowledge of their physician receiving payments/gifts from companies, and over one-third of respondents did not believe such compensation increased the cost of care. The majority of respondents agreed that patients should be aware of payments/gifts to physicians. (shrink)

When laypeople learned what decisions physicians were making about laypeople's health they were often appalled. … They discovered that physicians … were making controversial moral moves, choices th...

How did physicians come to dominate the medical profession? Lyn Bennett challenges the seemingly self-evident belief that scientific competence accounts for physicians' dominance. Instead, she argues that the whole enterprise of learned medicine was, in large measure, facilitated by an intensely classical education that included extensive training in rhetoric, and that this rhetorical training is ultimately responsible for the achievement of professional dominance. Bennett examines previously unexplored connections among writers and genres as well as competing livelihoods and (...) classes. Engaging the histories of rhetoric, medicine, literature, and culture throughout, she goes on to focus specifically on the work of women who professed as well as practiced medicine. Pointing to some of the ways women's writing shapes realities of body, mind, and spirit as it negotiates social, cultural, and professional ideologies of gender, this book offers an important corrective to some long-held beliefs about women's role in early modern discourse. (shrink)

The idea that physicians should accept recommendations from learned colleagues on how to practice medicine is probably as old as medicine itself, but beginning around 1990, it took on new urgency in the face of rising health care costs, widespread, unjustifiable variation in practice patterns, concerns about medical errors and quality of care, and what some perceived to be perverse effects of the malpractice system. One solution put forward was practice guidelines, which the Institute of Medicine defined as (...) systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. (shrink)

Baruch Spinoza’s (1632–77)Tractatus theologico-politicus (1669 or 1670) caused outrage across the Dutch Republic, for it obliterated the carefully installed separation between philosophy and theology. The posthumous publication of Spinoza’s Ethica, which is contained in his Opera posthuma (1677), caused similar consternation. It was especially the mathematical order in which the Ethica was composed that caused fierce opposition, for its mathematical appearance gave the impression that Spinoza’s heretical teachings were established demonstratively. In this essay, I document how the Dutch physician, local (...) politician, and amateur mathematician and experimenter Bernard Nieuwentijt (1654–1718) attempted to physico-mathematically and methodologically counter the threats posed by Spinoza’s program. Nieuwentijt tried to defend the authority of the scriptures in times at which they came under attack by the new philosophy and by the emerging sciences that were gradually winning terrain. The crux of his defense consisted in delineating a modest epistemology, a “learned ignorance,” that would cure Spinoza’s followers of their pansophical aspirations, on the one hand, and remove the conflict between the Bible and reason, on the other. The specific way in which he sought to accomplish this distinguished him from Dutch Reformed thought, or so I will argue. (shrink)

In “Medical Ethics: Common or Uncommon Morality,”1 Rosamond Rhodes defends a specialist view of medical ethics, specifically the ethics of physicians. Rhodes’s account is specifically about the ethics of medical professionals, rooted in what these professionals do. It would seem to follow that other healthcare professions might be subject to ethical standards that differ from those applicable to physicians, rooted in what these other professions do, but I leave this point aside for purposes of this commentary. Rhodes’s view (...) includes both a negative and a positive thesis. The negative thesis is that precepts in medical ethics—understood as the ethics of physicians—cannot be derived from principles of common morality. The positive thesis is two-fold: that precepts in medical ethics must be derived from an account of the special nature of what physicians do, and that this account is to be understood through an overlapping consensus of rational and reasonable medical professionals. While I agree emphatically with, and have learned a great deal from, Rhodes’s defense of the negative thesis, I disagree with both claims in Rhodes’s positive thesis, for reasons I will now explain after a brief observation about the negative thesis. (shrink)

This paper shows that in late seventeenth-century Scotland there existed a sizeable virtuoso community whose leaders were abreast of European developments in philosophy, history and science. Moreover, by c. 1700, Sir Robert Sibbald was attempting to organize a learned society modelled upon those he knew in Europe and upon London's Royal Society. The interests of the virtuosi and their attempts to institutionalize their pursuits laid much of the ground work for the Scottish Enlightenment. The Royal Society of Scotland which (...) Sir Robert hoped to found never became a reality, but the academic ideals which he propounded came to fruition in the Philosophical Society of Edinburgh and later bodies such as the Royal Society of Edinburgh and the Society of Antiquaries of Scotland. The intellectual inquiries and achievements of Sir Robert and his friends, particularly those in medicine and natural history, continued to be of interest to later Scots. They, thanks in part to the influence of the Newtonian physician Archibald Pitcaire, improved upon Sibbald's naïve Baconianism, but to a surprising degree their concerns had also been his. (shrink)

Error is a neglected epistemological category in the history of science. This neglect has been driven by the commonsense idea that its elimination is a general good, which often renders it invisible or at least not worth noticing. At the end of the sixteenth century across Europe, medicine increasingly focused on “popular errors,” a genre where learned doctors addressed potential patients to disperse false belief about treatments. By the mid-seventeenth century, investigations into popular error informed the working methodology of (...) natural philosophers, rather than just physicians. In 1646, Thomas Browne published Pseudodoxia Epidemica, a large volume on popular error. Despite Browne’s formal training as a physician, this work examined only a few medical errors and instead aspired to be an encyclopedia of error. Pseudodoxia Epidemica was highly popular, running to six editions, and was known by the Fellows of the Royal Society. Influenced by Browne, alongside Bacon’s theory of the idols, natural philosophic practice in the late sixteenth and seventeenth century developed a focus on error that revised traditional attention to the discovery of knowledge. Fellows such as Robert Boyle and Robert Hooke proposed new ways to secure truth under the far-reaching influence of Bacon’s refutations of “natural human reason” distorted by false idols, of syllogistic logic, and of “theories,” his label for traditional philosophical systems that bias thought toward falsity. In three parts, this article traces the progression in early modern scientific approaches to handling error, and especially medical error – from physicians’ efforts to identify and eradicate it through collaborative effort, to the striking tension in Browne’s work between seeking to eliminate error while also showing a marked tolerance for it, to the Royal Society’s Baconian objective of instrumentalizing error to find truth. Error emerges as its own epistemic category that serves as a driving force toward knowledge production. (shrink)

An ICU and Palliative Care specialist featured in the Netflix documentary Extremis offers a framework for a better way to exit life that will change our medical culture at the deepest level In medical school, no one teaches you how to let a patient die. Jessica Zitter became a doctor because she wanted to be a hero. She elected to specialize in critical care--to become an ICU physician--and imagined herself swooping in to rescue patients from the brink of death. But (...) then during her first code she found herself cracking the ribs of a patient so old and frail it was unimaginable he would ever come back to life. She began to question her choice. Extreme Measures charts Zitter's journey from wanting to be one kind of hero to becoming another--a doctor who prioritizes the patient's values and preferences in an environment where the default choice is the extreme use of technology. In our current medical culture, the old and the ill are put on what she terms the End-of-Life Conveyor belt. They are intubated, catheterized, and even shelved away in care facilities to suffer their final days alone, confused, and often in pain. In her work Zitter has learned what patients fear more than death itself : the prospect of dying badly. She builds bridges between patients and caregivers, formulates plans to allay patients' pain and anxiety, and enlists the support of loved ones so that life can end well, even beautifully. Filled with rich patient stories that make a compelling medical narrative, Extreme Measures enlarges the national conversation as it thoughtfully and compassionately examines an experience that defines being human. (shrink)

Past ages of medical care are condemned in modern philosophical and medical literature as being too paternalistic. The normal account of good medicine in the past was, indeed, paternalistic in an offensive way to modern persons. Imagine a Jean Paul Sartre going to the doctor and being treated without his consent or even his knowledge of what will transpire during treatment! From Hippocratic times until shortly after World War II, medicine operated in a closed, clubby manner. The knowledge learned (...) in medicine was not shared with the patients, who were in general poorly educated and for the most part completely ignorant of the craft of medicine and the physicians. Physicians were cautioned against telling patients too much about their Illness and/or their recovery, perhaps because physicians themselves did not have an enormous armamentarium to confront disease. (shrink)

Over one hundred years after Max Weber delivered his lecture “Science as a Vocation,” his description of the work of the physician in a disenchanted world still resonates. As a chronically ill patient who interacts with physicians frequently, I struggle with reconciling my understanding of my ill body with how my physician makes sense of my illness. My diagnosis created an existential crisis that caused me to search for meaning in my embodied experience, but I soon learned there (...) is little room for such a search within modern biomedicine. Instead, I turned to fine art to help me make sense of my ill body and its purpose in my life. With the aid of my printmaker sister, Darian Goldin Stahl, I have transformed the magnetic resonance images of my body into works of art, which help to re-enchant my body and give purpose to my illness. (shrink)

In this book, 11 leading scholars contribute to the understanding of the scientific and philosophical works of Moses Maimonides (1135-1204), the most luminous Jewish intellectual since Talmudic times. Deeply learned in mathematics, astronomy, astrology (which he strongly rejected), logic, philosophy, psychology, linguistics, and jurisprudence, and himself a practising physician, Maimonides flourished within the high Arabic culture of the 12th century, where he had momentous influence upon subsequent Jewish beliefs and behavior, upon ethical demands, and upon ritual traditions. For him, (...) mastery of the sciences was indispensable in the process of religious fulfilment. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Buddhist-Christian Studies 22 (2002) 214-217 [Access article in PDF] Book Review Toward a Contemporary Understanding of Pure Land Buddhism: Creating a Shin Buddhist Theology in a Religiously Plural World Toward a Contemporary Understanding of Pure Land Buddhism: Creating a Shin Buddhist Theology in a Religiously Plural World. Edited by Dennis Hirota. Albany: State University of New York Press, 2000. 257 pp. One of the lessons I learned from (...) Martin Luther is about "vocation." Basically, one's "vocation" is to express love and compassion toward all through engagement with the structures of existence that hinder justice through whatever social or occupational role (one's "calling") one occupies. In Luther's theology, there is no privileged ecclesiastical institution, no privileged theological class, and in his better moments, no privileged doctrinal system that mediates God's grace—meaning God's love and compassion. Instead, grace meets us where we are in the midst of whatever our "calling" might be; our "vocation" is to serve others in community through our callings: teacher, pastor, parent, physician, farmer, clerk, politician, or any other honest occupations by which persons make their way in the world. Luther's ideas of vocation—part of his doctrine of the "priesthood of all believers"—functioned as part of his critique of received medieval Christian tradition; it remains a defining theological principle of Protestant thought that Paul Tillich called the "Protestant principle."Being critical of Christian tradition is still widely practiced in mainline Protestant circles, even though Protestantism since Luther has produced absolutized forms of Luther's original critique of Christian tradition. My own Lutheran tradition is as guilty of this sort of idolatry as other Christian traditions. But the best of Protestant thought and practice has always generated critical attitudes in many theologians. So each generation of mainline Protestant theological reflection since Luther rejects, even as it builds upon, the work of previous generations, sometimes even retrieving elements of earlier tradition that their predecessors had rejected—as Luther retrieved Pauline-Augustinian notions of grace as a means of critiquing the sale of indulgences and the entire sacramental system of medieval Catholicism. [End Page 214]So as a Lutheran who believes that the process of personal and corporate self-criticism is an expression of faith, and that every attempt to absolutize any given form of tradition or religious practice is idolatry and constitutes nonfaith, I am always interested in learning how other religious traditions encourage personal and corporate self-criticism. As a Lutheran who happens to be a historian of religions engaged in interreligious dialogue, especially with Buddhists, and who has also thought and written about Pure Land Buddhism, I am especially intrigued when I encounter self-criticism similar to the Protestant principle at work in a form of Buddhism I deeply admire.Toward a Contemporary Understanding of Pure Land Buddhismis a collection of essays that evolved from a 1989 symposium planned by Dennis Hirota and sponsored by the Institute for Buddhist Studies that was held in Berkeley on campuses affiliated with the Graduate Theological Union. The focus of the conference—and of this volume—was constructive criticism of Jodo Shinshu Buddhist tradition. The essayists—three Buddhists and two Christians—share the conference's two convictions: (1) Pure Land Buddhism has a significant contribution to make to life in the contemporary world, and (2) Pure Land teachings and practices in the forms in which they are commonly communicated appear alien to contemporary persons both East and West. The structure of this collection flows from these convictions: first, three Pure Land authors (Dennis Hirota, John S. Yokota, and Musashi Tachikawa) offer three distinct proposals for deconstructing and reconstructing Pure Land Buddhism so that practitioners can more adequately reflect on contemporary intellectual and social circumstances as the context for faithful practice in a global context of religious and secularism pluralism, followed by critical comments on the Pure Land Buddhist proposals by two Christian theologians (Gordon D. Kaufman and John B. Cobb Jr.), and concluding with reconsiderations of their original proposals by the three Pure Land... (shrink)

Rural, remote, and northern Indigenous communities in Canada frequently face limited access to healthcare services with ongoing physician and staff shortages, inadequate infrastructure, and resource challenges. These healthcare gaps have produced significantly poorer health outcomes for people living in remote communities than those living in southern and urban regions who have timely access to care. Telehealth has played a critical role in bridging long-standing gaps in accessing healthcare services by connecting patients and providers across distance. While the adoption of telehealth (...) in Northern Saskatchewan is growing, its initial implementation faced several barriers related to limited and stretched human and financial resources, infrastructure challenges such as unreliable broadband, and a lack of community involvement and engaged decision-making. Emerging ethical issues during the initial implementation of telehealth in community contexts have been wide ranging including concerns around privacy that have also shaped patients’ experiences and particularly the need to consider place and space within rural contexts. Drawing from a qualitative study with four Northern Saskatchewan communities, this paper offers critical perspectives on the resource challenges and place-based considerations that are shaping telehealth in the Saskatchewan context and provides recommendations and lessons learned that could inform other Canadian regions and countries. This work responds to the ethics of tele-healthcare in rural communities in Canada and contributes perspectives of community-based service providers, advisors, and researchers. (shrink)

Claude Perrault, a founding member of the Académie des sciences and architect of the Louvre, is a figure emblematic of architecture’s transformation by the so-called scientific revolution, representing a radical break with tradition. This article will address Perrault’s scientific challenge to architecture as one that harks back to both ancient and modern sources. It explores some ways in which Perrault integrated the analogy between medicine and architecture into his approach to this art and assimilated medical concepts, particularly observation, into an (...) empirical medical approach. This notion of observation was at the heart of the practical aspect of ancient philosophy as a care of the soul which articulated the ancient comparison of the charismatic orator to a doctor. Thus, Perrault’s remarks on Vitruvius’s authority can be broadened beyond architecture to the quest for a guide to living, transcending disciplinary boundaries between natural science and art. Further, Perrault’s claims for naturalness in observation share a double perspective: observation as a new form of learned experience reflects the ethos of the scientist, while, as a traditional activity of peasants, it reflects a raw empirical knowledge about rules of life condensed into habit and custom, enabling common people to be the physicians of themselves. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Grieving One More TimeNeethi Pinto"The deeper sorrow carves into your being, the more joy you can contain."—Kahlil GibranI take care of very sick children in the pediatric intensive care unit (PICU). When a child dies, grief strikes in three distinct waves. First, I grieve for the child we couldn't heal, the unfairness, and the complete and utter sadness of a life cut too short. Then, I grieve for the (...) survivors—the families whose lives will be changed forever and who must find the strength to go on. It's not until later, in solitude, that I am able to grieve a third time—this time by and for myself.As clinicians, we are also survivors. Yet, our culture in medicine rarely affords us the permission or the grace to unpack the depth of the sorrow and grief we regularly witness and suffer. Instead, we must summon up the fortitude to take care of the child in the next room before we can pause and process our grief. As a field, we have been more intentional about having "hot" (soon after the event) and "cold" (days to weeks later) debriefings, but these short conversations about our shared experience are limited. The sheer reality of our day-to-day lives in the PICU is that the next critically ill patient is waiting.My processing of grief happens when I replay the events leading up to the patient's death over and over and over again. Was there something I missed? Could I have done better? In fact, I teach my medical students, pediatric residents, and PICU fellows that this very questioning makes us better physicians—as long as we don't let our second-guessing or fear of making a mistake paralyze our actions in the future.Little did I know I would grieve a fourth time …"How would you feel if this was your daughter?" These words were harshly spoken by my patient's father, a former police officer, the day his daughter died of respiratory failure. I had cared for her on many occasions during her prolonged admission, including that very sad last day. Undoubtedly, he was grieving, but I could feel his anger when he interrogated me. I wondered if he remembered how he profusely thanked me for caring for his daughter when we first met or the many times our team had resuscitated her, saving her life. I spent countless hours at her bedside, during the day, in the middle of the night, away from my own young family. Sure, these hours—nights, weekends, and holidays—are "part of the job," but I chose a career in pediatric critical care because of a commitment to caring for the most medically vulnerable children—the sickest of the sick—despite these hours. As pediatric intensivists, we have a unique opportunity to help children and their families at the most harrowing times in their lives—when they face the possibility of death. Although we know at the outset that some children will not survive, the grief we experience when a child dies still runs deep. It hurts every single time. In this case, my profound grief was exacerbated by the father's hostility. One year later, my sorrow deepened when I answered my doorbell at home to find a police officer handing me a subpoena for a malpractice lawsuit regarding this child's death—a delivery intended to intimidate me. I found myself grieving a fourth time—grieving for the loss of joy—joy that had been central to my identity as a physician. [End Page 72]Then, the feeling of shame crept in and haunted me. I always understood that I entered a high-risk/high-stakes field where children die because of the severity of their illness despite state-of-the-art medicine and technology. Over the years, I've learned that not only is it rewarding to help a child survive critical illness but it is incredibly moving to forge an intense human connection with families when their children are dying. So, my shame was not due to a sense of failure in preventing this child's death but rather due to the... (shrink)

Background: Chief nurses are most likely to take the lead in discussing and working to resolve ethical dilemmas, creating an ethical culture within their organization that results in effective ethics training. As the first step in this process, there is a need to define the kinds of ethical dilemmas that chief nurses grapple with on a regular basis as a target for future study. Research design: Anonymous written questionnaires and semi-structured interviews. Ethical considerations: All research procedures were approved by the (...) Chubu University Ethics Review Board, the research institution to which the authors belong (authorization no. 250016). Findings and discussion: Responses from four chief nurses indicated that ethical dilemmas could be categorized as either those related to patient dignity or those related to management (unique to their roles as administrators). It was also learned that chief nurses struggle with the fact that although they consult with their superiors and others, these efforts do not lead to resolution. The expectation is that going forward, chief nurses will play a central role in acting as coordinators with physicians to promote better communication as well as lead group discussions aimed at providing care that respects patient dignity. (shrink)