Futility and the obligations of physicians

It is becoming increasingly common (at least in the United States) for doctors to appeal to futility judgments as the basis for certain types of clinical decisions, such as the decision to withhold CPR. The clinical use of futility judgments raises two basic questions regarding futility. First, how is the concept of futility to be understood? Secondly, once we have a clearer understanding of futility, what role should determinations of futility play in clinical decision-making? Much of the discussion about the concept of futility has centered on the value-ladenness of futility judgments. I argue that futility determinations need to be distinguished from two other types of value-based judgments, namely, identification of the goals of treatment and treatment decisions based on an assessment of the benefits and burdens of treatment. If this distinction is sound, it suggests a very limited role for futility determinations in clinical decisionmaking, a role which should serve to promote communication between doctor and patient.     

Retrospective study of doctors' "end of life decisions" in caring for mentally handicapped people in institutions in The Netherlands.

OBJECTIVES: To gain insight into the reasons behind and the prevalence of doctors'' decisions at the end of life that might hasten a patient''s death ("end of life decisions") in institutions caring for mentally handicapped people in the Netherlands, and to describe important aspects of the decisions making process. DESIGN: Survey of random sample of doctors caring for mentally handicapped people by means of self completed questionnaires and structured interviews. SUBJECTS: 89 of the 101 selected doctors completed the questionnaire. 67 doctors had taken an end of life decision and were interviewed about their most recent case. MAIN OUTCOME MEASURES: Prevalence of end of life decisions; types of decisions; characteristics of patients; reasons why the decision was taken; and the decision making process. RESULTS: The 89 doctors reported 222 deaths for 1995. An end of life decision was taken in 97 cases (44%); in 75 the decision was to withdraw or withhold treatment, and in 22 it was to relieve pain or symptoms with opiates in dosages that may have shortened life. In the 67 most recent cases with an end of life decision the patients were mostly incompetent (63) and under 65 years old (51). Only two patients explicitly asked to die, but in 23 cases there had been some communication with the patient. In 60 cases the doctors discussed the decision with nursing staff and in 46 with a colleague. CONCLUSIONS: End of life decisions are an important aspect of the institutionalised care of mentally handicapped people. The proportion of such decisions in the total number of deaths is similar to that in other specialties. However, the discussion of such decisions is less open in the care of mental handicap than in other specialties. Because of distinctive features of care in this specialty an open debate about end of life decisions should not be postponed.     

ADEQUATE TRUST AVAILS,MISTAKEN TRUST MATTERS: ON THE MORAL RESPONSIBILITY OF DOCTORS AS PROXIES FOR PATIENTS' TRUST IN BIOBANK RESEARCH

In Sweden, most patients are recruited into biobank research by non‐researcher doctors. Patients' trust in doctors may therefore be important to their willingness to participate. We suggest a model of trust that makes sense of such transitions of trust between domains and distinguishes adequate trust from mistaken trust. The unique position of doctors implies, we argue, a Kantian imperfect duty to compensate for patients' mistaken trust. There are at least three kinds of mistaken trust, each of which requires a different set of countermeasures. First, trust is mistaken when necessary competence is lacking; the competence must be developed or the illusion dispelled. Second, trust is irrational whenever the patient is mistaken about his actual reasons for trusting. Care must therefore be taken to support the patient's reasoning and moral agency. Third, some patients inappropriately trust doctors to recommend only research that will benefit them directly. Such trust should be counteracted by nurturing a culture where patients expect to be asked occasionally to contribute to the common good.     

When (if ever) may doctors discuss religion with their patients?

There is ongoing debate within the bioethics literature regarding to what extent (if any) it is ethically justifiable for doctors to engage in religious discussion with their patients, in cases where patients cite religious considerations as influencing their medical decision-making. In this paper, we concede that certain forms of religious discussion between doctors and patients are morally permissible (though not necessarily morally obligatory), insofar as patients’ religious beliefs may comprise an important part of their overall wellbeing and can influence their medical decisions. However, we argue that it is not morally permissible for doctors to engage in substantive religious discussion with their patients, beyond simply inquiring about the patient's values (which may include their religious values) or referring patients to a chaplain or religious figure for further discussion. In support of this claim, we put forward two key arguments which have remained relatively unaddressed in the current debate. First, we argue that it is not practical for doctors to engage in substantive religious discussion with patients, and hence it cannot be morally obligatory for them to do so. Second, we argue that, while doctors might have a professional duty to ensure that their patient's religious interests (if any) are addressed, this does not entail that doctors themselves are the ones who should directly address these interests. Along the way, we anticipate and respond to some possible objections to these two key arguments.     

Misunderstandings in prescribing decisions in general practice: qualitative study

ObjectivesTo identify and describe misunderstandings between patients and doctors associated with prescribing decisions in general practice.DesignQualitative study.Setting20 general practices in the West Midlands and south east England.Participants20 general practitioners and 35 consulting patients.Results14 categories of misunderstanding were identified relating to patient information unknown to the doctor, doctor information unknown to the patient, conflicting information, disagreement about attribution of side effects, failure of communication about doctor''s decision, and relationship factors. All the misunderstandings were associated with lack of patients'' participation in the consultation in terms of the voicing of expectations and preferences or the voicing of responses to doctors'' decisions and actions. They were all associated with potential or actual adverse outcomes such as non-adherence to treatment. Many were based on inaccurate guesses and assumptions. In particular doctors seemed unaware of the relevance of patients'' ideas about medicines for successful prescribing.ConclusionsPatients'' participation in the consultation and the adverse consequences of lack of participation are important. The authors are developing an educational intervention that builds on these findings.     

Choosing between life and death: patient and family perceptions of the decision not to resuscitate the terminally ill cancer patient

In keeping with the pre-eminent status accorded autonomy within Australia, Europe, and the United States, medical practice requires that patients authorize do-not-resuscitate (DNR) orders, intended to countermand the default practice in hospitals of instituting cardiopulmonary-resuscitation (CPR) on all patients experiencing cardio-pulmonary arrest. As patients typically do not make these decisions proactively, however, family members are often asked to act as surrogate decision-makers and decide on the patient's behalf. Although the appropriateness of patients or their families having to decide about the provision of CPR has been challenged, there has been little examination of how patients and their families talk about and negotiate such decisions, particularly in the context of the patient's imminent death. In this article, part of a larger study analysing interviews with 28 patients (13 female) with cancer within weeks of their death, and 20 others (predominantly family) attending, we argue that a common assumption underpinning participants' talk about the DNR decision (i.e. forgoing CPR) is that it requires a choice between life and death. Using illustrative examples, we demonstrate that in making decisions about CPR, patients and their families are implicitly required to make moral judgements about the value of the patient's life, including their relationships with significant others. We identify some implications of these empirical observations for the development of ethically appropriate policies and practices regarding patient autonomy and surrogacy at the end of life.     

Survey of "do not resuscitate" orders in a district general hospital.

OBJECTIVE--To evaluate the local use of written "Do not resuscitate" orders to designate inpatients unsuitable for cardiopulmonary resuscitation in the event of cardiac arrest. DESIGN--Point prevalence questionnaire survey of inpatients'' medical and nursing records. SETTING--10 acute medical and six acute surgical wards of a district general hospital. PARTICIPANTS--Questionnaires were filled in anonymously by nurses and doctors working on the wards surveyed. MAIN OUTCOME MEASURES--Responses to questionnaire items concerning details about each patient, written orders not to resuscitate in the medical case notes and nursing records, whether prognosis had been discussed with patients'' relatives, whether a "crash call" was perceived as appropriate for each patient, and whether the "crash team" would be called in the event of arrest. RESULTS--Information was obtained on 297 (93.7%) of 317 eligible patients. Prognosis had been discussed with the relatives of 32 of 88 patients perceived by doctors as unsuitable for resuscitation. Of these 88 patients, 24 had orders not to resuscitate in their medical notes, and only eight of these had similar orders in their nursing notes. CONCLUSIONS--In the absence of guidelines on decisions about resuscitation, orders not to resuscitate are rarely included in the notes of patients for whom cardiopulmonary resuscitation is thought to be inappropriate. Elective decisions not to resuscitate are not effectively communicated to nurses. There should be more discussion of patients'' suitability for resuscitation between doctors, nurses, patients, and patients'' relatives. Suitability for resuscitation should be reviewed on every consultant ward round.     

我国暴力伤医事件成因的政策分析及应对

暴力伤医事件是我国医患信任解体的具体表现,并有逐年上升的趋势,它已严重威胁到医疗正常秩序。清晰的阐释其复杂的成因并提出政策应对建议,对减少暴力伤医以及构建和谐医患关系具有重要意义。本文旨在剖析伤医事件的成因的政策根源,并提出相应的政策应对策略及意见,进而为构建和谐的医患关系提供理论参考。     

Nationwide study of decisions concerning the end of life in general practice in The Netherlands.

OBJECTIVE--To gain insight into decisions made in general practice about the end of life. DESIGN--Study I: interviews with 405 physicians. Study II: analysis of death certificates with data obtained on 5197 cases in which decisions about the end of life may have been made. Study III: prospective study with doctors from study I: questionnaires used to collect information about 2257 deaths. The information was representative for all deaths in the Netherlands. RESULTS--Over two fifths of all patients in the Netherlands die at home. General practitioners took fewer decisions about the end of life than hospital doctors and doctors in nursing homes (34%, 40%, and 56% of all dying patients, respectively). Specifically, decisions to withhold or withdraw treatment to prolong life were taken less often. Euthanasia or assisted suicide, however, was performed in 3.2% of all deaths in general practice compared with 1.4% in hospital practice. In over half of the cases concerning pain relief or non-treatment general practitioners did not discuss the decision with the patient, mostly because of incapacity of the patient, but in 20% of cases for "paternalistic" reasons. Older general practitioners discussed such decisions less often with their patients. Colleagues were consulted more often if the general practitioner worked in group practice. CONCLUSION--Differences in work situation between general practitioners and hospital doctors and differences between the group of general practitioners contribute to differences in the number and type of decisions about the end of life as well as in the decision making process.     

基于因子分析法的医患信任危机成因研究

目的 探讨导致医患信任危机的多维影响因素与解决策略。方法 运用文献研究、专家咨询、现场调查及因子分析的方法,寻找对医患关系信任构成重要影响的潜在公因子,分析医患信任危机的成因。结果 医疗服务因子、医疗纠纷调解与行业监管因子、社会制度因素及文化价值因子、医患沟通因子是驱动医患信任危机形成的主因。结论 医患信任危机的形成受到医疗服务过程、外部社会制度及文化观念、行业监管及医患沟通和互动等多重因素的影响,需要政府、医疗机构和全社会共同努力,消解医患信任危机的坚冰,促进医患关系修复与和谐。     

Attitudes among NHS doctors to requests for euthanasia.

OBJECTIVES--To explore NHS doctors'' attitudes to competent patients'' requests for euthanasia and to estimate the proportion of doctors who have taken active steps to hasten a patient''s death. DESIGN--Anonymous postal questionnaire, with no possibility of follow up. The survey was conducted from December 1992 to March 1993. SUBJECTS--All (221) general practitioners and 203 hospital consultants in one area of England. RESULTS--273 doctors responded to a question on whether a patient had ever asked them to hasten death. Of these, 163 had been asked to; 124 of these had been asked to take active steps to hasten death; 38 of 119 (32%) of these had complied with such a request (95% confidence interval 23% to 40%). This proportion represented 12% of all those who returned a completed questionnaire and 9% of all those who had been sent a questionnaire (95% confidence interval 6.3% to 11.7%). A larger proportion of the respondents (142/307 (46%)), however, would consider taking active steps to bring about the death of a patient if it was legal to do so. CONCLUSIONS--Many doctors face difficult decisions about euthanasia. For the benefit of both patients and doctors euthanasia should be discussed more openly.     

Race and reputation: perceived racial group trustworthiness influences the neural correlates of trust decisions

Decisions to trust people with whom we have no personal history can be based on their social reputation-a product of what we can observe about them (their appearance, social group membership, etc.)-and our own beliefs. The striatum and amygdala have been identified as regions of the brain involved in trust decisions and trustworthiness estimation, respectively. However, it is unknown whether social reputation based on group membership modulates the involvement of these regions during trust decisions. To investigate this, we examined blood-oxygenation-level-dependent (BOLD) activity while participants completed a series of single-shot trust game interactions with real partners of varying races. At the time of choice, baseline BOLD responses in the striatum correlated with individuals' trust bias-that is, the overall disparity in decisions to trust Black versus White partners. BOLD signal in the striatum was higher when deciding to trust partners from the race group that the individual participant considered less trustworthy overall. In contrast, activation of the amygdala showed greater BOLD responses to Black versus White partners that scaled with the amount invested. These results suggest that the amygdala may represent emotionally relevant social group information as a subset of the general detection function it serves, whereas the striatum is involved in representing race-based reputations that shape trust decisions.     

Refugees' perspectives on barriers to communication about trauma histories in primary care

Objective This study explores refugees'' perspectives regarding the nature of communication barriers that impede the exploration of trauma histories in primary care.Method Brief interviews were conducted with 53 refugee patients in a suburban primary care clinic in the Midwest USA. Participants were asked if they or their doctors had initiated conversations about the impact of political conflict in their home countries. Qualitative data analysis was guided by grounded theory. Peer debriefings of refugee healthcare professionals were incorporated into the analysis.Results Two-thirds of refugee patients reported that they never shared how they were affected by political conflict with their doctors and that their doctors never asked them about it. Most refugees stated that they would like to learn more about the impact of trauma on their health and to discuss their experiences with their doctors.Conclusion Refugees are hesitant to initiate conversations with physicians due to cultural norms requiring deference to the doctor''s authority. They also lack knowledge about how trauma affects health. Physicians should be educated to inquire directly about trauma histories with refugee patients. Refugees can benefit from education about the effects of trauma on health and about the collaborative nature of the doctor–patient relationship.     

Dazed and Confused: Sports Medicine,Conflicts of Interest,and Concussion Management

Professional sports with high rates of concussion have become increasingly concerned about the long-term effects of multiple head injuries. In this context, return-to-play decisions about concussion generate considerable ethical tensions for sports physicians. Team doctors clearly have an obligation to the welfare of their patient (the injured athlete) but they also have an obligation to their employer (the team), whose primary interest is typically success through winning. At times, a team’s interest in winning may not accord with the welfare of an injured player, particularly when it comes to decisions about returning to play after injury. Australia’s two most popular professional football codes—rugby league and Australian Rules football—have adopted guidelines that prohibit concussed players from continuing to play on the same day. I suggest that conflicts of interest between doctors, patients, and teams may present a substantial obstacle to the proper adherence of concussion guidelines. Concussion management guidelines implemented by a sport’s governing body do not necessarily remove or resolve conflicts of interest in the doctor–patient–team triad. The instigation of a concussion exclusion rule appears to add a fourth party to this triad (the National Rugby League or the Australian Football League). In some instances, when conflicts of interest among stakeholders are ignored or insufficiently managed, they may facilitate attempts at circumventing concussion management guidelines to the detriment of player welfare.     

Situationally-sensitive knowledge translation and relational decision making in hyperacute stroke: a qualitative study

Stroke is a leading cause of disability. Early treatment of acute ischaemic stroke with rtPA reduces the risk of longer term dependency but carries an increased risk of causing immediate bleeding complications. To understand the challenges of knowledge translation and decision making about treatment with rtPA in hyperacute stroke and hence to inform development of appropriate decision support we interviewed patients, their family and health professionals. The emergency setting and the symptomatic effects of hyper-acute stroke shaped the form, content and manner of knowledge translation to support decision making. Decision making about rtPA in hyperacute stroke presented three conundrums for patients, family and clinicians. 1) How to allow time for reflection in a severely time-limited setting. 2) How to facilitate knowledge translation regarding important treatment risks and benefits when patient and family capacity is blunted by the effects and shock of stroke. 3) How to ensure patient and family views are taken into account when the situation produces reliance on the expertise of clinicians. Strategies adopted to meet these conundrums were fourfold: face to face communication; shaping decisions; incremental provision of information; and communication tailored to the individual patient. Relational forms of interaction were understood to engender trust and allay anxiety. Shaping decisions with patients was understood as an expression of confidence by clinicians that helped alleviate anxiety and offered hope and reassurance to patients and their family experiencing the shock of the stroke event. Neutral presentations of information and treatment options promoted uncertainty and contributed to anxiety. 'Drip feeding' information created moments for reflection: clinicians literally made time. Tailoring information to the particular patient and family situation allowed clinicians to account for social and emotional contexts. The principal responses to the challenges of decision making about rtPA in hyperacute stroke were relational decision support and situationally-sensitive knowledge translation.     

Patients' responsibilities in medical ethics

Patients have not been entirely ignored in medical ethics. There has been a shift from the general presumption that 'doctor knows best' to a heightened respect for patient autonomy. Medical ethics remains one–sided, however. It tends (incorrectly) to interpret patient autonomy as mere participation in decisions, rather than a willingness to take the consequences. In this respect, medical ethics remains largely paternalistic, requiring doctors to protect patients from the consequences of their decisions. This is reflected in a one–sided account of duties in medical ethics. Duties fall mainly on doctors and only exceptionally on patients. Medical ethics may exempt patients from obligations because they are the weaker or more vulnerable party in the doctor–patient relationship. We argue that vulnerability does not exclude obligation. We also look at others ways in which patient responsibilities flow from general ethics: for instance, from responsibilities to others and to the self, from duties of citizens, and from the responsibilities of those who solicit advice. Finally, we argue that certain duties of patients counterbalance an otherwise unfair captivity of doctors as helpers.     

Resource allocation and physician liability

Lawyer Karen Capen says funding cutbacks that have affected the services physicians can provide may cause legal problems for Canada''s doctors. If cutbacks affect the care that is being provided, they should be discussed with the patient and noted on the chart. She says physicians have "good reason to be concerned" about increasing pressures that create an imbalance between health care resources and the demand and need for services. For some doctors, these have resulted in court cases.     

For public or profession?--The new GMC performance procedures.

The upheaval in the General Medical Council two decades ago came from doctors not the consumers the council was set up to protect. Since then there have been repeated calls for doctors to improve their self regulation by amending the disciplinary procedures. Private member''s bills have failed and the GMC has now proposed performance procedures to deal with doctors who exhibit a "pattern of poor performance." After months of wide consultation in and outside the medical profession the GMC will decide next week whether to endorse the procedures, which unlike the conduct hearings will be inquiries by peers. Professor Margaret Stacey suggests that the procedures lack clarity, smacking of that "trust me" principle whose subtext is "but I''m not telling you what I''m up to."     

Unfakeable facial configurations affect strategic choices in trust games with or without information about past behavior

Background

Many human interactions are built on trust, so widespread confidence in first impressions generally favors individuals with trustworthy-looking appearances. However, few studies have explicitly examined: 1) the contribution of unfakeable facial features to trust-based decisions, and 2) how these cues are integrated with information about past behavior.

Methodology/Principal Findings

Using highly controlled stimuli and an improved experimental procedure, we show that unfakeable facial features associated with the appearance of trustworthiness attract higher investments in trust games. The facial trustworthiness premium is large for decisions based solely on faces, with trustworthy identities attracting 42% more money (Study 1), and remains significant though reduced to 6% when reputational information is also available (Study 2). The face trustworthiness premium persists with real (rather than virtual) currency and when higher payoffs are at stake (Study 3).

Conclusions/Significance

Our results demonstrate that cooperation may be affected not only by controllable appearance cues (e.g., clothing, facial expressions) as shown previously, but also by features that are impossible to mimic (e.g., individual facial structure). This unfakeable face trustworthiness effect is not limited to the rare situations where people lack any information about their partners, but survives in richer environments where relevant details about partner past behavior are available.