Ethics and evidence-based medicine: is there a conflict?

This article addresses the advantages, disadvantages, and traps to which evidence-based medicine (EBM) may lead and suggests that, to be ethically valid, EBM must be aimed at the patient's best interests and not at the financial interests of others. While financial considerations are by no means trivial, it is hypocritical - if not dangerous - to hide them behind words like "evidence" or "quality."

Framing issues in health care: do American ideals demand basic health care and other social necessities for all?

This paper argues for the necessity of universal health care (as well as universal free education) using a different argument than most that have been made heretofore. It is not meant to conflict with but to strengthen the arguments previously made by others. Using the second paragraph of the Declaration of Independence and the Preamble to the Constitution we argue that universal health care in this day and age has become a necessary condition if the ideals of life, liberty and the pursuit of happiness are to be more than an empty promise and if the discussion of "promoting of general welfare" in the preamble is to have any meaning.

Healthcare and the hospital chaplain.

Many chaplains and most chaplaincy programs in the United States--with encouragement from their accrediting organization, the Association for Clinical Pastoral Education (ACPE)--have begun to assume a more proactive stance toward patients, healthcare professionals, and healthcare facilities. Some chaplains and chaplaincy programs have begun to engage in activities that have ranged from initiating conversations with and perusing the medical records of patients who have not requested their services to proposing that they be permitted to do "spiritual assessments" on patients--in some instances whether these patients have been explicitly informed and have agreed to this beforehand. Moreover, many chaplains and chaplaincy programs have begun to assume that chaplains are full-fledged members of the healthcare team, complete with access to patients' medical records both to gather information and to make notations of their own.

Healthcare systems and motivation.

Despite the fact that most American physicians, at least until around the 1970s, stood in the way of developing a universal healthcare system, most are generally not happy with the current state of healthcare--or its lack thereof--today. The primary reasons for this general unhappiness are that insurance companies and managed care have successfully conspired to remove much of the physician's autonomy (via imposed time constraints, burdensome paperwork, the time-consuming chore of having to defend going against stringent treatment algorithms that are often inappropriate for some patients) and the satisfaction of knowing their patients. Few physicians in managed care organizations (MCOs) are able to practice without constant and blindly algorithmic interference concerning the diagnostic tests and therapeutic interventions they order.

Oaths for physicians--necessary protection or elaborate hoax?

The ritual of taking an oath upon graduating from medical school is, with a few exceptions, a routine requirement for graduation. Albeit that many students believe that they have taken the Hippocratic Oath, this is virtually never the case. Very often students themselves write many of these oaths, and taking such an oath impresses the student as well as the public, who are potential patients.

In defense of paternalism.

This paper argues that we have wrongly and not for the patient's benefit made a form of stark autonomy our highest value which allows physicians to slip out from under their basic duty which has always been to pursue a particular patient's good. In general - I shall argue - it is the patient's right to select his or her own goals and the physician's duty to inform the patient of the feasibility of that goal and of the means needed to attain it. If the goal is not one that is possible, the patient, with the physician and family, must select a feasible goal and then discuss the costs/benefits of various approaches.

Age discrimination at its best: should chronological age be a prime factour in medical decision making?

This paper briefly reviews the papers in this special section of HCA and makes the point--a point which should be obvious--that statistics are useful only as guidelines but tell one nothing about the individual patient in front of you. Chronological age merely shows what is true of most but decidedly not of all patients in a particular age group. To ration on the basis of age alone is unfair to the individual denied treatment and damaging to the community because it disturbs the solidarity which comes about because most members of the community feel that the community has obligations beyond those of not directly harming them; indeed, what produces solidarity is the feeling that members of a community will do their best to come to each others help.

Use and abuse of bioethics: integrity and professional standing.

This paper sets out to examine the integrity and professional standing of "Bioethics." It argues that professions have certain responsibilities that start with setting criteria for and credentialing those that have met the criteria and goes on to ultimately have social responsibilities to the community. As it now stands we claim that Bioethics--while it certainly has achieved some progress in the way medicine has developed--has failed to become a profession and has to a large extent failed in its social responsibility.

Advance directives. Good, bad or indifferent.

The author writes about various alternatives once decisional capacity is lost. So-called advance directives come in two forms: the living will and an appointed proxy for health care. The US--were these have been legally binding for over 20 years in all states--is a useful laboratory for studying the effect.

Principalism at the bed-side.

Using an actual case, this paper examines a number of ways in which physicians deal with such a case and with the various "principles" and ethical theories to which they are apt to appeal. It goes on to suggest that using Dewey's method of solving problems is most applicable at the bed-side.

Education, practice and bioethics: growing barriers to ethical practice.

While Bioethics is now taught at all medical colleges in the United States as well as in other nations, and while discussions about Bioethics have become frequent in most medical journals there are increasing barriers to teaching and incorporating what has been taught into daily practice. I shall discuss some of these barriers and suggest that integrating the teaching of Bioethics throughout the curriculum after presenting some of the basic theory and methodology is the most effective way of teaching this vital subject. Furthermore, courses in health care ethics are often taught as something distinct and distinguishable from one's medical practice.

Bioethics: past, present, and an open future.

The development of bioethics, spurred by the Nazi era and initiated in recent times largely in the United States, appears to be taking hold across at least the Western world. To date it lacks the necessary trappings of a true profession: that is, it lacks self-definition, criteria, and a method of assuring that those who call themselves bioethicists not only have appropriate training but function appropriately. Partly this is because the very term "appropriate" has not been defined! These are tasks that the new guard, with perhaps the advice and help of those of us from the old guard, will have to address.

Families, communities, and making medical decisions.

In his carefully crafted article, which, it is hoped, will stimulate further dialogue about this issue, David J. Doukas reviews some of the literature on this subject. He does not seem to differentiate between the family's role in decision making for competent or incompetent patients.

Oh death, where is thy sting? Reflections on dealing with dying patients.

This paper examines the reactions of physicians and other health professionals when they become involved in decisions about the death of their patients...

The uncertainty of certainty in clinical ethics.

Physicians accept fallibility in technical matters as a condition of medical practice. When it comes to moral considerations, physicians are often loathe to act without a good deal more certitude and seem less willing to accept error. This article argues that ethics is intrinsic to medical decision making, that error is the inevitable risk of any action and that inaction (clearly action by default) carries even greater risk of error.