Patients and physicians often perceive the current health care system to be unfair, in part because of the ways in which coverage decisions appear to be made. To address this problem the Ethical Force Program, a collaborative effort to create quality improvement tools for ethics in health care, has developed five content areas specifying ethical criteria for fair health care benefits design and administration. Each content area includes concrete recommendations and measurable expectations for performance improvement, which can be used by (...) those organizations involved in the design and administration of health benefits packages, such as purchasers, health plans, benefits consultants, and practitioner groups. (shrink)

*Disclaimer: The views expressed are the author's and should not be ascribed to the American Medical Association.

The threat of bioterrorism, the emergence of the SARS epidemic, and a recent focus on professionalism among physicians, present a timely opportunity for a review of, and renewed commitment to, physician obligations to care for patients during epidemics. The professional obligation to care for contagious patients is part of a larger "duty to treat," which historically became accepted when 1) a risk of nosocomial infection was perceived, 2) an organized professional body existed to promote the duty, and 3) the public (...) came to rely on the duty. Physicians' responses to epidemics from the Hippocratic era to the present suggests an evolving acceptance of the professional duty to treat contagious patients, reaching a long-held peak between 1847 and the1950's. There has been some professional retrenchment against this duty to treat in the last 40 years but, we argue, conditions favoring acceptance of the duty are met today. A renewed embrace of physicians' duty to treat patients during epidemics, despite conditions of personal risk, might strengthen medicine's relationship with society, improve society's capacity to prepare for threats such as bioterrorism and new epidemics, and contribute to the development of a more robust and meaningful medical professionalism. (shrink)

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

There are three broad ethical issues related to handling public health emergencies. They are the three R's - rationing, restrictions and responsibilities. Recently, a severe shortage of annual influenza vaccine in the US, combined with the threat of pandemic flu, has provided an opportunity for policy makers to think about rationing in very concrete terms. Some lessons from annual flu vaccination likely will apply to pandemic vaccine distribution, but many preparatory decisions must be based on very rough estimates. What ethical (...) principles should guide rationing decisions, what data should inform these decisions, how to revise decisions as new data emerge, and how to implement rationing decisions on the ground are all important considerations. In addition, ethicists might be able to help policy makers think through the importance of international cooperation in surmounting global rationing dilemmas and to accept the inevitable responsibilities of government in making and implementing rationing decisions. (shrink)

1. t. Viduramžiai, Renesansas, Naujieji amžiai.

The motive for late eighteenth-century proto-technics of photography and cinema was never quite mimetic representation: it was generating autonomous impressions of natural phenomena within the tradition ofNaturphilosophie. The article analyses a series of connections between ‘natural hieroglyphs’ (von Lichtenberg), Jacques-Alexandre-César Charles’s ‘megascope’, Wedgwood’s pre-photography, Lavater’s silhouettes and antecedents of Marey’s ‘graphic method’. The goal is to document precursor ideas, devices, setups and frameworks of photoimaging medias to show that the genealogy of photography and cinema intersected through many polymath transverses within (...) the ambit of natural philosophy (and the context of slavery). (shrink)

Confidentiality is a core value in medicine and public health yet, like other core values, it is not absolute. Medical ethics has typically allowed for breaches of confidentiality when there is a credible threat of significant harm to an identifiable third party. Medical ethics has been less explicit in spelling out criteria for allowing breaches of confidentiality to protect populations, instead tending to defer these decisions to the law. But recently, issues in military detention settings have raised the profile of (...) decisions to breach medical confidentiality in efforts to protect the broader population. National and international ethics documents say little about the confidentiality of detainee medical records. But initial decisions to use detainee medical records to help craft coercive interrogations led to widespread condemnation, and might have contributed to detainee health problems, such as a large number of suicide attempts several of which have been successful. More recent military guidance seems to reflect lessons learned from these problems and does more to protect detainee records. For the public health system, this experience is a reminder of the importance of confidentiality in creating trustworthy, and effective, means to protect the public's health. (shrink)

Patients and physicians often perceive the current health care system to be unfair, in part because of the ways in which coverage decisions appear to be made. To address this problem the Ethical Force Program, a collaborative effort to create quality improvement tools for ethics in health care, has developed five content areas specifying ethical criteria for fair health care benefits design and administration. Each content area includes concrete recommendations and measurable expectations for performance improvement, which can be used by (...) those organizations involved in the design and administration of health benefits packages, such as purchasers, health plans, benefits consultants, and practitioner groups. (shrink)

With this issue, we begin a regular feature on bioethics and public health. We welcome Matthew K. Wynia, M.D., M.P.H., Director of the Institute for Ethics of the American Medical Association as our new Contributing Editor. If you have comments or suggestions regarding this feature, please email us at manuscript@ bioethics.net.

In lieu of an abstract, here is a brief excerpt of the content:Conflicts—and Consensus—about Conflicts of Interest in MedicineMatthew K. Wynia and Bette–Jane Crigger*This fascinating collection of essays about individual experiences of conflict of interest leaves little doubt that physicians remain divided about the importance, impact and meaning of conflicts of interest in their work. These essays offer differing views about what conflicts of interest look and feel like “on the ground” and about whether specific conflicts of interest are (...) bad, just a fact of life, or maybe even good.Conflict, Conflict EverywhereThese essays situate conflict of interest in a variety of contexts: the treatment recommendations a physician makes for an individual patient; the relationship between teaching physician and medical student or practicing physician and health care organization; the interaction between academic researchers and industry collaborators or professional bodies and industry supporters. In this, the narratives taken together reflect the scope of concern about conflict of interest in medicine familiar in the literature. In his classic 1993 essay, Dennis Thompson noted that concerns about conflict of interest encompass issues of physician self–referral, risk sharing between physicians and health care institutions, gifts from industry, hospital purchasing practices, as well as sponsored research and research with patients (Thompson 1993). To that list have subsequently been added relationships with industry in medical education at all levels, physicians’ service as consultants to industry or members of industry speakers bureau, and development of clinical practice guidelines (Lo & Fields 2009).That almost none of these essays draw attention to some widely publicized situations of conflict of interest—for example, gifts to physicians or the provision of drug samples—should, we think, be seen more as an artifact of the authors’ varied individual experiences than as a failure by the authors to engage key concerns in the ongoing professional and public debate. It could also be that the authors, asked to submit personal stories, assumed that yet another essay about the ‘traditional’ issues in the conflicts of interest literature would be seen as redundant, routine or even boring. Or, there is the tantalizing possibility that the absence of some of the more familiar conflicts from these narratives is the early fruit of efforts to address these traditional issues through policies governing interactions between physicians and industry promulgated by academic medical centers and health systems, medical specialty societies, and industry.One significant area of concern that has emerged in recent years is conflict of interest in the development of clinical practice guidelines. E.g., Choudry et al. 2002; Sniderrman & Furberg 2009; Guyatt et al. 2010. Although none of the essays in this [End Page 101] collection address it head on, Perlmutter touches on several key issues. His depiction of how an FDA committee process limited the input he was able to provide as an expert, undermined his potential to contribute to the professional dialogue, and raised concerns about the objectivity of the drug approval process echoes concerns about objectivity, the role of expert opinion, and the presence on guideline development panels of individuals with financial interests in the recommendations to be developed that have been explored at some length in the literature, most recently by the Institute of Medicine in reports on evidentiary standards (Eden et al 2011) and principles for guideline development (Graham et al. 2011).Conflict of Interest or Dual Agency?Several essays set out physicians’ experience in navigating situations of diverging expectations. Bierut, for example, reflects on the disjunction between the goals and products of academic researchers and commercial sponsors. She saw herself advancing basic knowledge and was forced to grapple with the reality of sponsors’ goals to advance commercial ends as well. Nagldinne and Mikulec each recall struggles to reconcile their obligation to exercise professional judgment on behalf of patients with the demands of health care organizations focussed also on the bottom line. Cruz–Flores attests to the challenge of making recommendations for care when one is both a practicing clinician and a clinical investigator engaged in research that might offer benefit to a patient for whom there are limited options.Thompson defined conflicts of interest as “a set of conditions in which professional judgment concerning a primary interest (such as a patient’s welfare or the validity of... (shrink)

Volume 19, Issue 6, June 2019, Page 30-31.

Responses to public health emergencies can entail difficult decisions about restricting individual liberties to prevent the spread of disease. The quintessential example is quarantine. While isolating sick patients tends not to provoke much concern, quarantine of healthy people who only might be infected often is controversial. In fact, as the experience with severe acute respiratory syndrome (SARS) shows, the vast majority of those placed under quarantine typically don't become ill. Efforts to enforce involuntary quarantine through military or police powers also (...) can backfire, stoking both panic and disease spread. Yet quarantine is part of a limited arsenal of options when effective treatment or prophylaxis is not available, and some evidence suggests it can be effective, especially when it is voluntary, home-based and accompanied by extensive outreach, communication and education efforts. Even assuming that quarantine is medically effective, however, it still must be ethically justified because it creates harms for many of those affected. Moreover, ethical principles of reciprocity, transparency, non-discrimination and accountability should guide any implementation of quarantine. (shrink)

The term “Electronic Health Records” means something different to each of the stakeholders in health care, but it always seems to carry a degree of emotional baggage. Increasingly, EHRs are advertized as a nearly unmitigated good that will transform medical care, improve safety and efficiency, allow better patient engagement, and open the door to an era of cheap, effective, timely, and patient-centered care. Indeed, for some EHR proponents the benefits of adopting them are so obvious that adoption has become an (...) end in itself. But for others — and especially for a number of skeptical practitioners and patients — EHR is a code word that portends the corporate transformation of health care delivery, the loss of patient privacy, the demand that patients bear more responsibility in health care, and the unreflective takeover of the health care system by people who do not understand medical care or how health care relationships unfold. (shrink)

Volume 20, Issue 7, July 2020, Page 75-77.

*The views in this article are the author's alone and should not be construed as policy statements of the American Medical Association.

Recent arguments over whether certain public health interventions should be mandatory raise questions about what counts as a "mandate." A mandate is not the same as a mere recommendation or the standard of practice. At minimum, a mandate should require an active opt-out and there should be some penalty for refusing to abide by it. Over-loose use of the term "mandate" and the easing of opt-out provisions could eventually pose a risk to the gains that truly mandatory public health interventions, (...) such as childhood vaccines, have provided over the last 50 years. Already, confusion about what counts as a mandate, and about what criteria should be used to determine when a public health intervention should be implemented as a mandate, has led to some inappropriate public policy decisions. For instance, by any reasonable criteria, the yearly influenza vaccine should be mandatory for health care workers. To enforce this mandate, those who refuse vaccination should be required to sign a waiver, and patients - especially those at high risk from flu - should be informed when they receive care from unvaccinated practitioners. (shrink)

*The views expressed are the author's own. This article should not be construed as representing policies of the American Medical Association.

The American Journal of Bioethics, Volume 11, Issue 7, Page 1-2, July 2011.

*The views represented are the author's alone and should not be construed as representing policies of the American Medical Association.

The three primary ethical challenges in preparing for public health emergencies - addressing questions of rationing, restrictions and responsibilities - all entail confronting uncertainty. But the third, considering whether people and institutions will live up to their responsibilities in a crisis, is perhaps the hardest to predict and therefore plan for. The quintessential example of a responsibility during a public health emergency is that of health care professionals' obligation to continue caring for patients during epidemics. Historically, this 'duty to treat' (...) has sometimes gone unrecognized or ignored, but it has also famously been adhered to, including during the recent SARS epidemic. And non-crisis examples of health professionals working in the face of personal risk are very common. The duty to treat should be circumscribed by several considerations, including the levels or risk and benefit at issue, the degree of public reliance on health professional action, and the nature of the individual health professional's acceptance of greater than usual risk. Examining the professional duty to treat and the legitimate questions it raises can provide insight into other actors' responsibilities. Public health ethics as well as professional ethics can help frame answers to some key questions: How strong are ethical responsibilities during crises? To whom do they apply? Should they be more explicit - and hence more circumscribed - or less explicit and hence largely aspirational? And how can public health policies encourage responsible actions? (shrink)

The Centers for Disease Control and Prevention (CDC) recently recommended that HIV screening should become routine for all adults in the United States. Implicit in the CDC proposal is the notion that pre-test counseling would be more limited than at present, and that written informed consent to screening would no longer be required. If widely implemented, routine testing would mark a tremendous shift in the US HIV screening strategy. There are a number of considerations used to determine what screening tests (...) should be routine, and HIV fits the bill in almost every regard. Yet the stigma associated with HIV infection remains, making the CDC's recommendation highly controversial. Will minimizing requirements for pre-test counseling and special written informed consent lead to unexpected or unwanted HIV testing, or do these stringent counseling and consent requirements needlessly scare people away? Will widespread and routine testing be associated with declining stigmatization, or will it drive some patients away from seeking desperately needed health care? These are high stakes questions, and we're about to find out the answers. (shrink)

* Disclaimer: The views expressed are the author's own. This article should not be construed as representing policies of the American Medical Association.

Each year, infection with Human Papillomavirus (HPV) leads to millions of abnormal Pap smears and thousands of cases of cervical cancer in the US. Throughout the developing world, where Pap smears are less common, HPV is a leading cause of cancer death among women. So when the international pharmaceutical giant Merck developed a vaccine that could prevent infection with several key strains of HPV, the public health community was anxious to celebrate a major advance. But then marketing and lobbying got (...) in the way. Merck chose to pursue an aggressive lobbying campaign, trying to make its new vaccine mandatory for young girls. The campaign stoked public mistrust about how vaccines come to be mandated, and now it's not just Merck's public image that has taken a hit. The public health community has also been affected. What is the lesson to be learned from this story? Public health communication relies on public trust. (shrink)

Anne Barnhill focuses her article in this issue on the American Medical Association's ethics policy governing clinical use of placebos, but the implications of her analysis are deeper, touching on how physicians should make judgments about which interventions to offer patients in the process of shared decision‐making. The bottom line is that, even if an undisclosed placebo might be marginally more effective for a particular patient in the short term, over the long haul the integrity of the patient‐physician relationship relies (...) on doctors being honest with their patients. Even when it comes to placebos, honesty remains the best policy. (shrink)

Keď sa ľudia nachádzajú medzi inými, správajú sa viac prosociálne, morálne a štedro. Čo však môže ovplyvniť ich správanie v momente, keď sú sami? Aby sa správali ako medzi inými? Jedna z možností môže byť vyvolať pocit, že sa niekto pozerá. Tento účel môže splniť aj obyčajné zrkadlo. Naše výskumy podporujú vplyv zrkadla na dodržiavanie pravidla na súboroch dospelých a detí. V obidvoch experimentoch prítomnosť zrkadla zvyšovala šancu na dodržiavanie stanoveného pravidla. Ako však niečo tak jednoduché ako zrkadlo môže ovplyvniť (...) správanie? Jeden z prístupov tvrdí, že vizuálny stimul spustí automatickú percepciu „niekto sa pozerá“, aj napriek tomu, že je to iba odraz v zrkadle. Ďalší možný prístup vychádza z predpokladu, že na seba upriamená pozornosť vyvoláva sebauvedomovanie, pričom sa zviditeľňuje prípadný rozpor medzi konaním a štandardom. Porušenie pravidla v takom momente by mohlo ohroziť sebaúctu. V treťom prístupe autori vychádzajú z princípu negatívnej spätnej väzby. Nakoniec by sme radi spomenuli naše experimenty a navrhli ďalšie možnosti skúmania v tejto oblasti. (shrink)

Since physicians began to formally professionalize in the 19th century, we have sought to set ourselves apart from other occupations through the adoption (and variable enforcement) of codes of ethi...

The topic of safeguarding against sickness grew in importance during the COVID-19 pandemic. People’s health was more at risk, yet not all had the same capacity and options to deal with it. Therefore, this article focuses on the under-researched topic of choice of strategies and individual practices for safeguarding against one’s sickness among micro-entrepreneurs (with 1–10 employees) before and during the pandemic, namely on the example of Czechia. We analyse 30 qualitative interviews with micro-entrepreneurs to demonstrate how their social location (...) affects the attainability of strategies and individual practices for that purpose. It is primarily their family role (breadwinner vs caregiver) that, along with socioeconomic status, either limits or opens choices of strategies and individual practices or combinations thereof. Although the COVID-19 pandemic posed a high health risk to the entire society, it did not bring the micro-entrepreneurs to revise their often-risky choices in safeguarding against sickness. In contrast, it highlighted some specifics of micro-enterprises, e.g. their unclear organisational structure, which proved a high risk in the context of the health crisis. (shrink)

There is an old saw in health policy that everyone wants health care that is good, fast, and cheap — but it’s impossible to have more than two of these at one time.A similar bit of folk wisdom seems intuitively true for the development and testing of new pharmaceutical products. The public is in a bind. We want breakthrough drugs, and fast. But we also want these drugs to be affordable, thoroughly tested, safe, and effective. It seems we can’t have (...) it all.In this paper, we will not claim that one can have it all — but that we can do far better than we are at present. First, we review extensive data on contemporary problems in the design, conduct, and analysis of industry-sponsored clinical trials. Finding major issues that have been solidly documented over more than a decade, we provide many examples of the multifarious ways in which industry-funded trials have been manipulated to raise the likelihood of producing industry-friendly results. (shrink)

*The views expressed are the author's own. This article should not be construed as representing policies of the American Medical Association.

As we write, U.S. cities and states with extensive community transmission of Covid‐19 are in harm's way—not only because of the disease itself but also because of prior and current failures to act. During the 2009 influenza pandemic, public health agencies and hospitals developed but never adequately implemented preparedness plans. Focused on efficiency in a competitive market, health systems had few incentives to maintain stockpiles of essential medical equipment. Just‐in‐time economic models resulted in storage of only those supplies needed then. (...) At the same time, global purchasing in search of lower prices reduced the number of U.S. suppliers, with hospitals dependent on foreign companies. There is still a possibility that the pandemic will be manageably bad rather than unmanageably catastrophic in this country. Immediate, powerful, and sustained federal action could make the difference. (shrink)